The Role of RTs in Patient Assessment

1
The Role of RTs in Patient Assessment

• Robert L. Wilkins, PhD, RRT, FAARC
• Professor of CPS
• Loma Linda University

2
Objectives

• State how the role of RTs has changed over the
  past thirty years in patient assessment.
• Identify the assessment procedures physicians
  want RTs to be able to perform.
• Identify the assessment skills RTs should possess
  to perform competent patient care.
• List the steps of diagnostic reasoning and be
  able to state examples of each step.

3
Final Exam

• Who is pictured?
• What year is it?
• What city?
• What disease is probably being diagnosed?

4
History of Patient Assessment in Respiratory Care

• How can we measure changes in the role of RTs
  with regards to pt. assessment?
• Interview individuals who have been around a long
  time
• Review educational material that has defined the
  standards of care over time

5
History of Patient Assessment in Respiratory Care

• Egans first edition (1969)
• One author
• 12 chapters
• 474 pages
• Published by C.V. Mosby

6
History of Patient Assessment in Respiratory Care

• 8th edition of Egans (2003)
• Three editors 46 contributors
• 49 chapters 1375 pages
• Published by Mosby (Elsevier)

7
History of Patient Assessment in Respiratory Care

• Which of the following terms related to pt.
  assessment can be found in the index of the 1st
  8th eds of Egans?
• stethoscope wheeze
• rales/crackles stridor
• cough tachypnea
• fever hemoptysis

8
History of Patient Assessment in Respiratory Care

• ANSWERS
• 1st edition none
• 8th edition all of them

9
History of Patient Assessment in Respiratory Care

• 1st edition content
• of chapters ¼ (ABG chapter)
• of pages 7
• of figures 1

• 8th edition
• of chapters 5
• of pages 141
• of figures 95

10
History of Patient Assessment in Respiratory care

• What has changed over the past 30 years?
• RTs are now expected to perform patient
  assessment (now standard of care)
• They are called on to evaluate patients with any
  type of breathing problem
• This is to be applied to all ages of patients in
  any type of health care setting

11
What do Physicians Expect of RTs in the
Assessment Domain?

• Surveyed 25 critical care MDs from 2 So. Cal.
  Hospitals
• Asked them to rate how important they feel it is
  for RTs to be able to perform or interpret 20
  different assessment procedures
• Each assessment test or procedure was rated on a
  scale of 1 to 5 1 never 5 always

12
What do Physicians Expect of RTs in the
Assessment Domain?

• Results (20 of 25 surveys returned)
• 1. Assess lung sounds (4.8)
• 2. Interpret ABGs (4.5)
• 3. Interpret PFTs (4.4)
• 4. Assess vital signs (4.4)
• 5. Interview patient to clarify symptoms (4.3)

13
What do Physicians Expect of RTs in the
Assessment Domain?

• Results
• Procedures rated the lowest
• 1. Interpret echocardiography (2.5)
• 2. Assess abdomen (2.3)
• 3. Interpret sleep studies (2.2)
• 4. Interpret EEGs (1.7)

14
What do Physicians Expect of RTs in the
Assessment Domain?

• Conclusions
• Physicians have high expectations of RTs with
  regards to procedures related to the lungs
• This is true regardless of years of experience or
  type of specialty (e.g. pulmonary vs. surgery)
• Respir Care 47583 2002

15
What should RTs be able to do?

• Establish a rapport with the patient
• Interview to assess symptoms related to lung
  problems
• Check vital signs/sensorium
• Assess breathing pattern and rate

• Assess lung sounds
• Assess for cyanosis
• Interpret ABGs
• Interpret PFTs
• Read CXRs for specific findings
• Interpret CBC and electrolyte panel

16
Assessment of Dyspnea

• Pathophysiology
• Increase in the work of breathing
• Increase in the drive to breathe
• Decrease in the breathing capacity
• Ratio of PI to Pimax
• PI pressure needed to take single breath
• PImax maximum pressure capability

17
Assessment of Dyspnea

• Increases in PI
• Narrowed airways
• Asthma
• COPD
• Decreased lung compliance
• pneumonia
• Obesity

• Decreases in PImax
• Neuromuscular dz
• Severe hyperinflation
• Nutritional deficits
• Hypoxia
• Hyperkalemia

18
Assessment of Dyspnea

• Factors the increase the drive to breathe
• Acidosis
• Hypoxia
• Anxiety
• Exercise
• Atelectasis

19
Treatment of Dyspnea

• Increase Pimax
• Reverse hypoxia
• Correct electrolyte imbalances
• Reduce hyperinflation
• Improve muscle function

• Reduce PI
• Bronchodilators
• Diuretics
• CPAP
• PPV

20
Treatment of Dyspnea

• Reduce the drive to breathe
• oxygen therapy
• correct acidosis
• lung expansion therapy

21
Assessment of Breathing Pattern

• Best indicator of lung function in post-op
  patients is respiratory rate at rest
• IE and degree of prolonged expiratory time
  predicts FEV1 in asthmatics
• Prolonged inspiratory time upper airway
  obstruction
• Abdominal parodox diaphragm fatigue in COPD
  patients

22
Assessing Lung Sounds

• Characteristics of wheezing to note in
  asthmatics
• Length of respiratory cycle occupied by wheezing
• Pitch of the wheeze
• Intensity of wheeze (poor predictor)
• Length and pitch of wheeze correlate best with
  FEV1

23
Assessing ABGs

• pH 7.28 PCO2 38, PO2 44, HCO3- 14
• Interpretation Metabolic and Respiratory
  Acidosis
• Predicted PCO2 in met. Acidosis 1.5 x bicarb
  8 2
• 1.5 x 14 21 8 29
• PCO2 in this case is 38 and RA

24
Patient Assessment Case Study

• 37 yr old male admitted for cervical fusion of
  three vertebrae
• Surgery went well 4 hrs post-op patient began to
  complain of SOB
• RT called to see patient since attending
  physician had gone home

25
Patient Assessment Case Study

• RT interviewed pt and auscultated no abnormal BS
  heard vitals normal
• RT determined SOB due to extubation
• Suggested cool mist and SpO2 monitoring
• Also suggested med neb with racemic epinephrine

26
Patient Assessment Case Study

• Patient had no improvement with tx in fact SOB
  and difficulty in swallowing worse
• Nurse pages RT again and states patient is much
  worse
• RT says SpO2 normal on FIO2 of 0.40 and treatment
  may take some time

27
Patient Assessment Case Study 1

• Patient continues to deteriorate and nurse is
  concerned enough to page RT again
• RT responds to the ICU
• SpO2 99 but patient now extremely anxious and
  upset
• RT auscultates and finds no abnormalities he
  repeats med neb

28
Patient Assessment Case Study 1

• RN calls MD and reports concerns MD speaks to RT
  and RT convinces MD that pt is experiencing upper
  airway inflammation from extubation and anxiety
• MS ordered to calm patient
• Patient becomes less anxious but remains SOB and
  unable to swallow

29
Patient Assessment Case Study 1

• One hour later patient codes
• ER MD comes and tries to intubate but is unable
  to pass tube
• Emergency trach is done but patient expires
• Autopsy reveals large hemorrhage in neck trachea
  open lt 1.5 cm

30
Patient Assessment Case Study 1

• Mistakes by RT
• Assumed SpO2 of gt95 no respiratory problems
• Interpreted no stridor as sign that the upper
  airway was patent
• Did not order ABG to assess ventilation

31
Patient Assessment Case Study 1

• 4. Did not stay with patient
• 5. Did not see downward trend
• 6. Remained convinced extubation trauma was the
  cause
• 7. Did not use Steps of Diagnostic Reasoning

32
Steps of Diagnostic Reasoning

• ID patient problem
• Clarify the problem
• Perform additional assessment procedures
• Formulate list of potential causes

• 5. Obtain specialized tests
• 6. Determine potential solutions
• 7. Evaluate solution and monitor patient

33
Cognitive skills needed for Diagnostic Reasoning

• Analyze
• Evaluate
• Interpret
• Compare trends
• Independent thinking
• Knowledge of pathophysiology

34
Case Study 2

• JB is a 64 yr old male with a hx of COPD
• He comes to the ER with acute SOB, cough and
  fever he is alert and orient.
• RT is paged to see patient
• RT and MD determine pt may have pneumonia and
  exacerbation of COPD

35
Case Study 2

• Patient admitted for tx and monitoring
• IPPB treatments ordered with bronchodilator
• Sputum culture ordered
• CBC and electrolytes ordered
• IV antibiotics started

36
Case Study 2

• Patient stabilizes over the next four hours and
  after two IPPB treatments and low flow O2
• CXR reveals pneumonia in LUL
• Patient goes to bed around 10 pm and is somewhat
  comfortable but still SOB

37
Case Study 2

• Same RT paged early next am to see JB
• JB is now very SOB and disoriented
• Heavy use of accessory muscles (new)
• RN says please give JB his IPPB tx stat
• RT starts setting up tx but decides to assess
  patient again

38
Applying Steps of Diagnostic Reasoning

• ID pt problem
• Clarify problem
• Perform additional dx procedures
• Formulate list of potential causes
• Obtain specialized tests

• SOB and disoriented
• SOB suddenly worse
• BS absent on right bruise on rt lower chest
• Pneumonia, COPD, pneumo, PE
• ABG, CXR CXR revealed large pneumothorax

39
Applying Steps of Diagnostic Reasoning

• 6. Determine potential solutions
• 7. Evaluate solutions and monitor patient

• Chest tube increase FIO2
• Patient stabilizes with chest tube and oxygen
  therapy

40
Case Study 3

• 38 yr old female is brought to the ER for severe
  dyspnea
• Pt has a one year history of asthma
• Current SOB occurred while performing duties at
  her construction job
• Pt denies fever, cough, chest pain

41
Case Study 3 (cont.)

• RT sees pt before giving bronchodilator tx
  ordered by ER MD
• Pt has stable vitals with normal breathing
  pattern monophonic wheezing is heard loudest on
  the right
• RT pages medical director and suggests patient
  does not have asthma

42
Case Study 3 (cont.)

• CXR ordered and is normal
• Pulmonologist called and evaluated pt
  bronchoscopy eventually done
• A benign growth is found in the right main stem
  bronchus
• Following surgery, patient returns to work and is
  asymptomatic

43
Role of RTs in Patient Assessment Summary

• RTs are now expected to be skilled at assessment
  of pt with CP disease
• MDs rely on RTs when they cant be there
• RTs need to stay current with research related to
  patient assessment
• RTs can benefit from learning to use the steps of
  diagnostic reasoning

44
How do you know youre living California?

• Your childs 3rd grade teacher has purple hair, a
  nose ring, and is named Breeze
• A colleague at work states she has five body
  piercings and none are visible
• Youve been to a baby shower that has two mothers
  and a sperm donor

45
Final Exam

• Who is pictured?
• What year is it?
• What city?
• What disease is probably being diagnosed?

46
Bibliography

• Wilkins RL Clinical Assessment in Respiratory
  Care, Mosby, ed 5, 2005, St. Louis.
• Wilkins RL and Hodgkin JE Fundamentals of Lung
  and Heart Sounds, Mosby, ed 3, 2004, St. Louis.
• My email bwilkins_at_llu.edu