1. P ATIENT D ATA E VALUATION AND R ECOMMENDATIONS Collect and Evaluate Pertinent Clinical Information

2. Assessment is one of the most important skills needed to perform as a competent RCP Obtaining pertinent clinical information at the bedside helps you Determine the patient’s medical condition Develop the proper treatment plan Evaluate the patient’s response to therapy

3. NBRC E XPECTATIONS Your assessment skills and knowledge must be excellent if the patient is to receive the best possible care

4. C OMMON E RRORS TO A VOID ON THE E XAM Don’t assume that all that wheezes are asthma; patients with congestive heart failure may also exhibit wheezing due to peribronchial edema Don’t assume that a lack of central cyanosis means satisfactory oxygenation; a patient with anemia can be severely hypoxemic without cyanosis Never delay needed interventions for a newborn in order to assess Apgar score Do not use a numeric pain scale with young children or patients who are unable to express themselves

5. M ORE C OMMON E RRORS TO A VOID ON THE E XAM Do not attempt patient education until all major barriers to learning have been resolved Do not use mechanical (vane-type) respirometers to measure forced vital capacities. Do not try to determine the nature of a patient's pulmonary impairment based on the peak expiratory flow measure. Never accept bedside spirometry results until yo have three acceptable maneuvers. Do not use apnea monitoring or auto-CPAP to assess patients for obstructive apnea

6. M ORE C OMMON E RRORS TO A VOID ON THE E XAM Do not use the six minute walks test (6MWT) to identify the cause of a patient’s dyspnea or exercise intolerance Do not use a cycle ergometer when titrating a patient’s supplemental O2 needs Do not remove patients from PEEP/CPAP to measure CVP or PCWP Never forget to deflate the balloon of a pulmonary artery catheter To prevent infection, do not routinely replace indwelling catheters.

7. E XAM S URE B ETS Always consider peripheral cyanosis, coolness of the extremities, and slow capillary refills as signs of cardiac failure. Always consider recommending airway clearance for patients whose sputum production exceeds 30 mL/day Always think pulmonary edema when a patient has pink. frothy secretions. Always remember that the trachea and PMI shift toward areas of atelectasis and away from space- occupying lesions such as pneumothoraces or pleural effusions.

8. M ORE E XAM S URE B ETS If you detect crepitus, always consider the possibility of pneumothorax (and immediately communicate your findings to the doctor). When you detect a pulse deficit, you can be sure there is a cardiac arrhythmia, such as atrial fibrillation. Recognize that only alert patients can cooperate and fully participate in their own care. Always consider a patient to be comatose if the Glasgow score is less than 8.

9. M ORE E XAM S URE B ETS Tachypnea, thoracic-abdominal dysyncrony, and use of accessory muscles always indicate increased work of breathing. Whenever in doubt regarding DNR status, always initiate emergency life support or resuscitation when needed. When reading an x-ray, always verify patient identification and film orientation Always consider foreign body aspiration as a possibility in the differential diagnosis of airway obstruction in children (and justification for recommending both chest and lateral neck x- rays).

10. M ORE E XAM S URE B ETS High breathing rates and low tidal volumes always increase deadspace ventilation per minute. To consider a change in a pulmonary flow parameter to be clinically significant, expect at least a 15% improvement from baseline. The primary indicator of an abnormal cardiopulmonary exercise test is a low VO 2max. For accurate vascular pressure measurements, ensure that the transducer is at the same level as the pressure it measures, typically the patient’s plebostatic axis

11. R EFERENCE : Certified Respiratory Therapist Exam Review Guide, Craig Scanlon, Albert Heuer, and Louis Sinopoli Jones and Bartlett Publishers