THE

RESPIRATORY
ASSESSMENT COMPANION

ANATOMY OF THE RESPIRATORY SOUNDS

LUNGS
Trachea

Primary
Bronchus RHONCHI
Secretions in larger airways

Rumbling, course
sounds
GAS EXCHANGE IN THE ALVEOLI May clear with cough
or suction
Blood low COPD, Pneumonia
Blood high
in O2, high in O2, low Secondary NORMAL RHONCHI
in CO2 Air moves in and out in CO2 Bronchus
of Alveolus
WHEEZING
Red Blood Alveolar Airway narrowing in Bronchioles
Cells Wall
Musical noise during
inspiration/expiration
CO2 O2 Usually louder during
diffuses diffuses Tertiary expiration
out of into Bronchus Asthma, Bronchitis
blood blood
NORMAL WHEEZING

Bronchioles
RALES
Secretions in Terminal Bronchi & Alveoli

Terminal
Bronchiole Crackles, fluid in Alveoli
In the red blood cells,
hemoglobin molecules CHF, Pneumonia
bond with the oxygen Respiratory
for delivery to the cells. Bronchiole

Alveolar Sac NORMAL RALES

A STEP-BY-STEP METHOD FOR ANALYZING ABGS TIPS

ΠIs the pH out of range? Reference Ranges TO ENSURE ACCURACY OF PULSE
 Is the pCO2 normal? pH 7.35–7.45 OXIMETER
Does the capillary refill in less than 3
Ž Is the HCO2 out of range? pCO2 35–45 mmHg seconds?
 Match the abnormal result with the pH? HCO3 22–26 mEq/L Does pulse reading match the heart rate
 Does the PaCO2 or HCO3 go in the opposite (HR)?
direction of the pH? pO2 80–100 mmHg Validate with arterial blood gas (ABG).
‘
Is the pO2 and SO2 out of range? SO2 95–100%
pO2 : FiO2 RATIONALE
Take the pO2 from the ABG
Divide by the FiO2
RESPIRATORY ALPHABET SOUP Change % to a decimal
The results should be greater than 300. 200 or less
ABG Arterial blood gas PCO2 Partial pressure of carbon dioxide
indicates respiratory failure.
CO2 Carbon dioxide PaCO2 Partial pressure of carbon dioxide in
FiO2 Fraction of inspired oxygen arterial blood
HCO3 Bicarbonate pH Potential of hydrogen FOR BEST OXYGEN SATURATION
H2CO3 Carbonic Acid PvCO2 Partial pressure of carbon dioxide in Normalize pH and body temperature.
venous blood
HR Heart rate
SO2 Oxygen saturation
O2 Oxygen
SaO2 Oxygen saturation in arterial blood RESPIRATORY QUICK CHECK
PO2 Partial pressure of oxygen
SvO2 Oxygen saturation in venous blood Perfusion is best in the bases and in the back.
PaO2 Partial pressure of oxygen in arterial blood
TCO2 Total carbon dioxide content Assess and treat there first.
PvO2 Partial pressure of oxygen in venous blood

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 THE
CARDIOVASCULAR
ASSESSMENT COMPANION

ANATOMY OF THE THE HEART WALL ABNORMAL PULSES

HEART Aorta
Fibrous Pericardium
Parietal Pericardium
Pericardial Space
(filled with pericardial fluid)
WEAK, THREADY PULSE
Cause: Shock

BOUNDING PULSE
Superior Epicardium
Vena Cava Causes: Hyperdynamic phase of sepsis
Myocardium Hypertension
Pulmonary
Trunk Endocardium
PULSUS ALTERNANS (STRONG, WEAK)
Pulmonary The pericardial space Cause: Severe cardiac dysfunction
Valve Left Atrium (filled with pericardial
fluid):
PULSUS PARADOXUS
Aortic • Limits the movement of
Valve the heart Causes: Mechanical ventilation
Right • Protects it from infections
Atrium coming from other organs Air trapping (asthma, COPD)
• Prevents excessive dilation Cardiac tamponade
Mitral/ of the heart
Bicuspid Valve
Tricuspid • Lubricates the heart
Valve SHOCK PERIPHERAL PULSES
Fluid Pulse 0 Absent
Left Ventricle Shock Type
Volume Pressure
Right Ventricle 1 Diminished, weak
Hypovolemic â Narrow
+2 Brisk, expected
Inferior Cardiogenic á Narrow
Vena Cava Cardiac Muscle +3 Increased
Septic â Wide +4 Bounding

CARDIOVASCULAR
FLUID VOLUME: (PRELOAD) RESISTANCE: (AFTERLOAD) PUMP PERFORMANCE QUICK CHECK
(CARDIAC OUTPUT)
• CVP (0-8 mmHg) • SVR (800-1400 dynes) • CO (4-8 L/min) Use changes in vital signs to signal
• PAOP (5-12 mmHg) • Diastolic blood pressure • Systolic blood pressure changes in hemodynamics. Compare
• JVD • Skin color and temp • Skin color and temp
• Dependent edema • Capillary refill every new measurement to the
• Organ function
•I&O • Organ dysfunction previous ones, and talk about the
• Daily weights change in hemodynamic terms.

HEART ELECTRICAL DISORDERS

S4 S1 S2 S3
SICK SINUS SYNDROME (SSS) VENTRICULAR TACHYCARDIA (VT)
• Heart rate can alternate between slow and fast • Heart rate that is regular and rapid
• Indicates that the heart’s natural electrical pacemaker, • Heart beat starts in the lower part of the heart (Ventricles)
the Sinus Node, is not working properly
VENTRICULAR FIBRILLATION (VF)
SINUS TACHYCARDIA • Heart rate that is regular and rapid which cause the Ten- - - - - - Nes - - - - - - See
• A harmless, faster rhythm that happens with fever, Ventricles of the heart to quiver uselessly, instead of A- - - - - - - Stiff - - - - - Wall
excitement, and exercise pumping blood
S4:
• Causes blood pressure to plummet, cutting off blood
ATRIAL FIBRILLATION (AF OR AFIB) Indicates MI (myocardial infarction) & hypertension
supply to the vital organs Low pitched and soft
• Heart rate is irregular and rapid
PREMATURE CONTRACTIONS Best heard with the bell
• Is caused by disorganized signals from the heart’s
electrical system • Extra, early, or “skipped” beats are the most common
cause of irregular heart rhythms
ATRIAL FLUTTER (AFL)
• Heart rate is regular and rapid LONG QT SYNDROME (LQTS) S4 S1 S2 S3
• Is caused by a single electrical wave that circulates very • Disorder of the electrical system
rapidly in the atrium
HEART BLOCK
JUNCTIONAL RHYTHM • Heart rate is too slow
• Occurs when the AV Node takes over as the primary • Caused when the electrical signals from the upper
pacemaker site in the heart either because the SA node chambers of the heart (Atria) cannot travel to the lower Ken- - - Tuck- - - - - Y
has failed or the AV Node is going faster and over takes chambers (Ventricles) Slosh- - Ing - - - - - In
the SA Node
• Juntional rhythm: 40-60 beats per minute SYNCOPE (FAINTING) S3:
• A heart rhythm disorder that causes fainting or feeling Indicates CHF (congestive heart failure)
• Accelerated junctional rhythm: 60-100 beats per minute
as if one might pass out Low pitched and soft
• Junctional tachycardia: greater than 100 beats per minute Best heard with the bell

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 THE
GENITOURINARY
ASSESSMENT COMPANION

Adrenal Gland
ANATOMY OF THE
URINARY
Aorta Renal Vein

Renal Cortex

Renal Papilla

Renal Pyramids
SYSTEM
Renal Columns

Fibrous Capsule
NEPHRON
Proximal Distal
Convoluted Convoluted
Tubule Tubule
Renal Pelvis
Kidney Glomerular
Capsule
Ureter

Glomerulus Collection
Duct

Urinary
Bladder
Nephron Loop

Sphincter
Muscle Urine
Nephron are the functional unit of the storage and
kidney that produce urine in the process elimination
Urethra of removing waste and excess substances
from the blood. There are about 1,000,000
Nephrons in each human kidney.

GU QUICK CHECK URINE COLOR INTERPRETATION

Decreased urine
output could be from WHITE ORANGE PINK OR RED
dehydration or acute renal Over hydration Dehydration, food, Blood, drugs, food
vitamins, liver dysfunction
dysfunction—check the
creatinine clearance. PALE YELLOW SYRUP BLUE OR GREEN
Normal Severe dehydration, liver Food, bacterial infection,
dysfunction medications

DARK YELLOW DARK BROWN

Dehydration, vitamins Severe dehydration, liver
dysfunction

AMBER OR SMOKEY BROWN

HONEY Drugs
Dehydration, vitamins

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 THE
NEUROLOGIC
ASSESSMENT COMPANION

ANATOMY OF THE BRAIN Frontal

Lobe

Parietal
Lobe
Limbic Lobe

Corpus Callosum

Thalamus Occipital
Lobe
Optic Schiasma
Pineal Gland
Hypothalamus Temporal
Lobe
Pons

Pituitary Medulla
Gland Oblongata
Mammillary
Body Cerebellum

Spinal Cord

5-POINT GLASGOW COMA SCALE

NEURO CHECK EYE OPENING E
Spontaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
BEST To speech . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ΠBehavior To pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
No response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
 Speech
BEST MOTOR RESPONSE M
Ž Content Obeys command . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Localizes pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
 Arousability Flexion-withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Flexion-abnormal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
 Systolic BP Extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
WORST No response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

BEST VERBAL RESPONSE V

Oriented and converses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Disoriented and converses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
NEURO QUICK CHECK Inappropriate words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
CONSCIOUS PATIENT Incomprehensible sounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Watch his/her behavior No response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

UNCONSCIOUS PATIENT 8 OR LESS: 9 TO 12: 13 TO 15:

Watch his/her systolic blood pressure Severe head injury Moderate head injury Mild head injury

Mortality and functional capacity is inversely related to GCS.

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 THE
GASTROINTESTINAL
ASSESSMENT COMPANION

ANATOMY OF THE GI TRACT BACTERIAL FLORA

Esophagus GOOD FLORA
PANCREAS Stomach
Liver
Splenic BIFIDOBACTERIA
Artery Gallbladder
Portal Vein Spleen Bifidobacteria helps to regulate other
bacteria, modulate immune responses
Bile Duct to invading pathogens, prevent tumor
formation, and produce vitamins.
Body of
Pancreas ESCHERICHIA COLI
1 Some strains of Escherichia Coli help to
F
Head of Tail of Pancreas produce vitamin K2 and help to keep
Pancreas Pancreas bad bacteria in check. Bad strains can
D cause illness.
E
Superior
Mesenteric Vein Uncirate C LACTOBACILLI
Superior Process Beneficial strains produce vitamins and
Mesenteric Artery nutrients, boost immunity, and protect
2
against carcinogens.
B
G

BAD FLOR A
INTESTINAL VILLI 3
H

Appendix Rectum CAMPYLOBACTER

Some strains of Campylobacter
Villi
are most commonly associated
Epithelial Anus with human disease. Infection
Cell usually occurs through ingestion
of contaminated food.
Lacteal
Mucosa
LARGE INTESTINE
ENTEROCOCCUS FAECALIS
Capillary A Cecum Can cause endocarditis and septicemia,
Network urinary tract infections, meningitis, and
B Teniae coil
other infections in humans. Common
SMALL INTESTINE C Ascending colon cause of post-surgical infections.
Arteriole
1 Duodenum D Right colic flexure
Lymphatic
2 Jejunum E Transverse colon CLOSTRIDIUM DIFFICILE
Vessel
Causes colitis by producing toxins that
Venule 3 Ileum F Left colic flexure damage the lining of the colon. Most
harmful following a course of antibiotics
G Descending colon when it is able to proliferate.
H Sigmoid colon

GI QUICK CHECK
HOW DIGESTION WORKS Absent bowel sounds and abdominal pain
signal bowel infarction.
MOUTH PANCREAS
Chewing breaks food into smaller pieces, Connected to the top of the small intestine, BOWEL SOUNDS
mixing it with enzymes in your saliva. the pancreas manufactures three important HYPERACTIVE HYPOACTIVE
Starches begin to digest. enzymes to digest lipids, carbohydrates,
Infarction
proteins, and nucleic acids. It also produces Diarrhea
ESOPHAGUS Perforation
Insulin which controls the amount of sugar in GI bleeding
The esophagus moves the food from the Ileus
the blood. Colitis
Narcotics
mouth to the stomach. Enteritis
Surgery
SMALL INTESTINE
STOMACH Most of the nutrients from the food is
The food mixes and grinds with gastric juices,
SIGNS OF PERITONITIS
absorbed through the intestine lining known
• Pain
which help digest proteins and other foods as the mucosa.
• Rebound tenderness
while minimizing harmful bacteria.
• Diminished bowel sounds
LARGE INTESTINE
• Taut abdominal muscles
LIVER What is left over from the small intestine
• Nausea / vomiting
The liver produces bile which is released travels into the large intestine. Here, water, • Fever
into the small intestine. It helps to break fat-soluble vitamins, and minerals are • Shock
down fats and fatty acids so they are more absorbed. Living bacteria called flora break • Respiratory failure
easily absorbed. down and extract what small amount of
nutrients are left. The waste left over will Condition HCT BUN
GALLBLADDER then exit the body.
A storage tank for the extra bile produced Dehydration á á
by the liver. The gallbladder releases the bile GI Bleed â Norm
into the small intestine when it is needed. Overhydration â â

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 THE
PATHOLOGY
ASSESSMENT COMPANION

LABS TO WATCH
Basic Metabolic Panel Complete Blood Count
Normal Values Normal Values
Glucose 70-100 mg/dL White blood cells (WBC) 4500-10000
Calcium 9.0-10.5 mg/dL Red blood cells (RBC) 4.2-6.1
Sodium 135-145 mmol/L
Hemoglobin (Hb) 12.1-17.2
Potassium 3.5-5.0 mEq/L
Hematocrit (HCT) 36-50%
CO2 23-29 mmol/L
Platelets 150,000-450,000
Chloride 95-103 mEq/L
BUN 8-20 mg/dL Mean corpuscular volume (MCV) 80-95

Creatinine 0.7-1.2 mg/dL Mean corpuscular hemoglobin (MCH) 27-31

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