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2014 wilkins clinical assessment in respiratory care 7e with MCQ


Contents


1. PREPARING FOR THE PATIENT ENCOUNTER, 1



2. THE MEDICAL HISTORY AND THE INTERVIEW, 15



3. CARDIOPULMONARY SYMPTOMS, 32



4. VITAL SIGNS, 56



5. FUNDAMENTALS OF PHYSICAL EXAMINATION, 73




6. NEUROLOGIC ASSESSMENT, 102



7. CLINICAL LABORATORY STUDIES, 126



8. INTERPRETATION OF BLOOD GASES, 152



9. PULMONARY FUNCTION TESTING, 178



10. CHEST IMAGING, 207



11. INTERPRETATION OF ELECTROCARDIOGRAM TRACINGS, 234



12. NEONATAL AND PEDIATRIC ASSESSMENT, 263



13. OLDER PATIENT ASSESSMENT, 296



14. RESPIRATORY MONITORING IN CRITICAL CARE, 314



15. VASCULAR PRESSURE MONITORING, 348



16. CARDIAC OUTPUT MEASUREMENT, 373



17. BRONCHOSCOPY, 396



18. NUTRITION ASSESSMENT, 410



19. SLEEP AND BREATHING ASSESSMENT, 436



20. HOME CARE PATIENT ASSESSMENT, 453



21. DOCUMENTATION, 468



GLOSSARY, 486



Albert J. Heuer, PhD, MBA, RRT, RPFT
Program Director, Masters in Health Care Management &
Associate Professor, Respiratory Care Program-North
School of Health Related Professions
University of Medicine and Dentistry of New Jersey
Newark, New Jersey

Craig L. Scanlan, EdD, RRT, FAARC
Professor Emeritus
School of Health Related Professions
University of Medicine and Dentistry of New Jersey
Newark, New Jersey


3251 Riverport Lane
Maryland Heights, Missouri 63043

WILKINS’ CLINICAL ASSESSMENT IN RESPIRATORY CARE
ISBN: 978-0-323-10029-8
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Copyright © 2010, 2005, 2000, 1995, 1990, 1985 by Mosby Inc., an affiliate of Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher.

Notice
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment, and drug therapy may become necessary or
appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or


formula, the method and duration of administration, and contraindications. It is the responsibility of
the practitioners, relying on their own experience and knowledge of the patient, to make diagnoses, to
determine dosages and the best treatment for each individual patient, and to take all appropriate safety
precautions. To the fullest extent of the law, neither the Publisher nor the Editors/Authors assume any
liability for any injury and/or damage to persons or property arising out of or related to any use of the
material contained in this book.
The Publisher
Library of Congress Cataloging-in-Publication Data
Wilkins’ clinical assessment in respiratory care / [edited by] Albert J. Heuer, Craig L. Scanlan. – 7th ed.
p. ; cm.
Clinical assessment in respiratory care
Rev. ed. of: Clinical assessment in respiratory care / Robert L. Wilkins, James R. Dexter ; consulting editor,
Albert J. Heuer. 6th ed.
c2010.
Includes bibliographical references and index.
ISBN 978-0-323-10029-8 (pbk. : alk. paper)
I. Heuer, Albert J. II. Scanlan, Craig L., 1947- III. Wilkins, Robert L. Clinical assessment in respiratory care.
IV. Title: Clinical assessment in respiratory care.
[DNLM: 1. Diagnostic Techniques, Respiratory System. 2. Physical Examination.
3. Respiratory Therapy–methods. WF 141]
617’.075—dc23
2012045666

Content Strategy Director: Jeanne Olson
Content Manager: Billi Sharp
Senior Content Development Specialist: Kathleen Sartori
Publishing Services Manager: Gayle May
Project Manager: Deepthi Unni
Design Direction: Maggie Reid

Printed in the United States of America
Last digit is the print number:  9  8  7  6  5  4  3  2  1


Through the leadership and scholarly commitment of
Dr. ­Robert  L. Wilkins, PhD, RRT, this text has become a cornerstone resource in respiratory patient assessment and is used
by a majority of respiratory programs worldwide. This accomplishment can be attributed directly to the significant and sustained efforts of Dr. Wilkins, through the many editions of this
text for which he has been senior editor. Simply stated, this book
is current, thorough, concise, and clearly written. As a result of
his untimely death, Dr. Wilkins’ presence in preparing this edition was greatly missed, and maintaining his high standard
was a challenge. However, both editors for this seventh edition,
Dr. Craig Scanlan and I, had worked with Bob on other projects,
including prior editions of this and other texts. In addition, we
assembled a team of returning and new contributors. These factors, coupled with the appropriate retention of content written by Dr. Wilkins for prior editions, have resulted in what
we believe is worthy of the standard and style set by Dr. Wilkins. In recognition and appreciation of his contributions to this text and to respiratory therapy education, this text has been
renamed Wilkins’ Clinical Assessment in Respiratory Care. Dr. Wilkins is deeply missed by me on
a personal and professional level, and his absence from our profession will be felt for some
time. However, his legacy will live on in the memory of his family, friends, and colleagues, as
well as the pages of this text.
Warmly, Al Heuer

To Dr. Robert L. Wilkins and Dr. Craig L. Scanlan for their unwavering
mentorship, to my lovely wife Laurel for her patience and support,
and to the students, faculty, and my fellow respiratory therapists, who are
constant sources of inspiration.
AJH
To Mom and Dad who believed in me;
to Barrie and Craig Patrick, in whom I believe.
CLS


Sixth Edition Editors/Contributors
Douglas D. Deming, MD
Professor of Pediatrics
Loma Linda University
Medical Director of Neonatal Respiratory Care
Medical Director of ECMO
Loma Linda University Children’s Hospital
Loma Linda, California

James A. Peters, MD, DrPH, MPH, RD, RRT, FACPM
Attending Physician, Preventive Medicine
Department of Internal Medicine and Center for Health
St. Helena Hospital and Health Center;
Physician and Owner
Nutrition and Lifestyle Medical Clinic
St. Helena, California

De De Gardner, MSHP, RRT, FAARC
Associate Professor and Chair
Department of Respiratory Care
School of Health Professions
University of Texas Health Science Center at San Antonio
San Antonio, Texas

Helen M. Sorenson, MA, RRT, FAARC
Assistant Professor
Department of Respiratory Care
School of Health Professions
University of Texas Health Science Center at San Antonio
San Antonio, Texas

Susan L. McInturff, RCP, RRT
Clinical Director
Farrell’s Home Health
Bremerton, Washington

Cheryl Thomas Peters, DCN, RD
Clinical Manager St. Helena Center for Health
St. Helena, California

S. Gregory Marshall, PhD, RRT, RPSGT, RST
Associate Professor/Chair
Department of Respiratory Care
College of Health Professions
Texas State University—San Marcos
San Marcos, Texas

vi

Richard Wettstein, BS, RRT
Assistant Professor
Department of Respiratory Care
School of Health Professions
University of Texas Health Science Center at San Antonio
San Antonio, Texas


Contributors

Robert F. Allen, III, MA, RPSGT
Manager, Sleep Wake Disorder Lab
St. Mary’s Medical Center
Langhorne, Pennsylvania
Zaza Cohen, MD, FCCP
Assistant Professor
Fellowship Program Director
Division of Pulmonary and Critical Care Medicine
University of Medicine and Dentistry of New Jersey
Newark, New Jersey
Cara DeNunzio, MPH, RRT, CTTS
Adjunct Assistant Professor
Respiratory Care Program—North
School of Health Related Professions
University of Medicine and Dentistry of New Jersey
Newark, New Jersey
Nadine A. Fydryszewski, PhD, MLS
Associate Professor
School of Health Related Professions
University of Medicine and Dentistry of New Jersey
Newark, New Jersey
David A. Gourley, RRT, MHA, FAARC
Executive Director of Regulatory Affairs
Chilton Hospital
Pompton Plains, New Jersey
Elaine M. Keohane, PhD, MLS
Professor and Chairman
Department of Clinical Laboratory Sciences
University of Medicine and Dentistry of New Jersey
Newark, New Jersey

Kenneth Miller, MEd, RRT-NPS, AE-C
Educational Coordinator, Dean of Wellness
Respiratory Care Services
Lehigh Valley Health Network
Allentown, Pennsylvania
Ruben D. Restrepo, MD, RRT, FAARC
Professor
Director, Bachelor’s Completion Program
School of Health Professions
Department of Respiratory Care
University of Texas Health Science Center
San Antonio, Texas
Narciso Rodriguez, BS, RRT-NPS, RPFT, AE-C
Assistant Professor and Program Director
Respiratory Care Program
University of Medicine and Dentistry of New Jersey
School of Health Related Professions
Newark, New Jersey
David L. Vines, MHS, RRT, FAARC
Chair and Program Director
Department of Respiratory Care
Rush University
Chicago, Illinois
Jane E. Ziegler, MD, DCN, RD, LDN
Assistant Professor
Graduate Programs in Clinical Nutrition
School of Health Related Professions
University of Medicine and Dentistry of New Jersey
Newark, New Jersey

vii


Reviewers
Georgine Bills, MBA/HAS, RRT
Program Director, Respiratory Therapy
Dixie State College of Utah
St. George, Utah
Craig P. Black, PhD, RRT-NPS, FAARC
Director, Respiratory Care Program
The University of Toledo
Toledo, Ohio
Helen Schaar Corning, AS, RCP, RRT
Shands Jacksonville Medical Center
Jacksonville, Florida
Erin Ellis Davis, MS, MEd, RRT-NPS, CPFT
Director of Clinical Education-Clinical Coordinator
Our Lady of Holy Cross College/Ochsner Health System
New Orleans, Louisiana
Dale Bruce Dearing, RCP, RRT, MSc
Respiratory Therapy Program Assessment Coordinator
San Joaquin Valley College
Visalia, California
Lindsay Fox, MEd, RRRT-NPS
Respiratory Care Program Coordinator
Southwestern Illinois College/St. Elizabeth Hospital
Belleville, Illinois
Laurie A. Freshwater, MA, RCP, RRT, RPFT
Health Sciences Division Director
Carteret Community College
Morehead City, North Carolina
Christine A. Hamilton, DHSc, RRT, AE-C
Assistant Professor, Director of Clinical Education
Cardio-Respiratory Care Sciences Program
Tennessee State University
Nashville, Tennessee
Sharon L. Hatfield, PhD, RRT, RPFT, AE-C, COPD-C
Chair of Community Health Sciences, Associate Professor
of Respiratory Therapy and Healthcare Management
Jefferson College of Health Sciences
Roanoke, Virginia

viii

Robert L. Joyner, PhD, RRT, FAARC
Associate Dean and Director, Respiratory Therapy
Program
Henson School of Science & Technology
Salisbury University
Salisbury, Maryland
Chris Kallus, MEd, RRT
Professor and Program Director
Victoria College Respiratory Care Program
Victoria, Texas
Kevin Shane Keene, DHSc, RRT-NPS, CPFT, RPSGT
Program Director
Respiratory Care
University of Cincinnati
Cincinnati, OH
Tammy Kurszewski, MEd, RRT
Director of Clinical Education, Respiratory Care
Midwestern State University
Wichita Falls, Texas
J. Kenneth LeJeune, MS, RRT, CPFT
Program Director Respiratory Education
University of Arkansas Community College at Hope
Hope, Arkansas
Stacy Lewis-Sells, EdM, RRT-NPS, CPFT, AE-C
Program Director for Respiratory Care
Southeastern Community College
West Burlington, Iowa
Cory E. Martin, EdS, RRT
Program Director, Associate Professor
Volunteer State Community College
Gallatin, Tennessee
Michael McLeland, MEd, RPSGT, RST
Program Director
Sanford-Brown College
Fenton, Missouri
Harley R. Metcalfe, BS, RRT
Adjunct Professor. Respiratory Care Program
Johnson County Community College;
Vice President
PM Sleep Lab LLC
Overland Park, Kansas


REVIEWERS

ix

Michell Oki, MPAcc, RRT RPFT, RPSGT
Assistant Professor
Weber State University Respiratory Therapy
Ogden, Utah

Shawna L. Strickland, PhD, RRT-NPS, AE-C, FAARC
Clinical Associate Professor
University of Missouri
Columbia, Missouri

Timothy Op’t Holt, EdD, RRT, AE-C, FAARC
Professor
University of South Alabama
Mobile, Alabama

Cam Twarog, RRT-NPS, BSRT, MBA
Director of Clinical Education
Respiratory Care Practitioner Program
Wheeling Jesuit University
Wheeling, West Virginia

Sara Parker, BHS-RT, RRT-NPS, AE-C
Clinical Instructor
University of Missouri School of Health Professions
Columbia, Missouri
José D. Rojas, PhD, RRT
Associate Professor
University of Texas Medical Branch
Galveston, Texas
Paula Denise Silver, BS Biology, PharmD
Medical Instructor
ECPI University
Newport News, Virginia
Helen M. Sorenson, MA, RRT, FAARC
Associate Professor Department of Respiratory Care
UT Health Science Center
San Antonio, Texas

Michael D. Werner, MS, RRT, CPFT
Respiratory Therapy Program Director
Concorde Career College North Hollywood
Los Angeles, California

Ancillary Authors
Craig P. Black, PhD, RRT-NPS, FAARC
Director, Respiratory Care Program
The University of Toledo
Toledo, Ohio
Jill H. Sand, MEd, RRT
Program Chair Respiratory Care
Southeast Community College
Lincoln, Nebraska


Preface

The primary purpose of the seventh edition is the same as
the previous ones: to provide relevant information related
to the knowledge and skills needed for respiratory therapists (RTs) to be competent and to trust in their patient
assessment skills. The seventh edition is based on the
assumption that every patient is an interactive, complex
being who is more than a collection of his or her parts. The
health status of patients depends on many internal and
external environmental interactions. These interactions
occur within their physical environments and include
what they eat, drink, and breathe; how they sleep; and if
and when they exercise. External or social environments
also affect their health status and include what kind of
activity and work they participate in and where they live.
Other factors, such as when, why, and how often patients
seek health care, can also affect their overall well-being.
Although the language of this text continues to be
aimed primarily at students, experienced therapists or
other health care clinicians may benefit from its content as
well. We hope that this book helps students and clinicians
gain important insight into the value, purpose, and skills
associated with patient assessment. The important tools
provided in these pages can assist you to inspect and examine the patient’s body. However, learning to listen to the
patient’s explanation of what is wrong and right is often
the most valuable practice in meeting a patient’s health
needs.
Assisting physicians in assessing patients for the treatment needed, the complications that may arise, and
when treatment regimen should be changed or discontinued is a competency expected of almost all health care
professionals.
We have seen firsthand the difference in patient care
when clinicians are competent at patient assessment. Identifying the early signs of atelectasis through the use of a
stethoscope and evaluation of breathing pattern, identifying the potential misplacement of an endotracheal tube
through the use of a stethoscope and the chest radiograph,
and recognizing serious abnormalities based on the arterial blood gas are all scenarios in which you could find
yourself.
Application of such skills can favorably affect the outcomes experienced by patients both in and outside the hospital. On the other hand, those clinicians who lack good
assessment skills generally are relegated to following the
orders of others, which is not always the best way to serve
the patient. Although we believe that high-tech equipment
can be smart and sophisticated, it can never replace the
well-honed bedside assessment skills of the experienced
clinician. We hope that the knowledge in this book will
x

help develop and refine your clinical skills and inspire you
to develop a passion for patient assessment.

New to This Edition
The seventh edition retains the strengths of the first six
editions: a clear, approachable writing style; an attractive
and user-friendly format; and the inclusion of relevant
clinical case studies and helpful hints for practice. However, this new edition ushers in many significant changes:
• With the passing of the author, Robert Wilkins, in September 2010, two highly experienced respiratory care
textbook editors have now assumed primary responsibility for the book, which now bears his name.
• Albert J. Heuer is a long-time respiratory educator
and is Associate Professor for the Respiratory Care
Program at the University of Medicine and Dentistry
in Newark, New Jersey. Dr. Heuer served as contributor and consulting editor on the sixth edition and is a
coeditor of Egan’s Fundamentals of Respiratory Care, 10th
edition. Dr. Heuer is a practicing respiratory therapist who continues to work regularly in acute care at
a major medical center in New Jersey. It was because
of his expertise as a respiratory educator, scholar, and
clinician, coupled with their professional relationship,
that Robert Wilkins requested to have Dr. Heuer succeed him as lead editor for this project. Dr. Heuer is
continuing Wilkins’ legacy in maintaining the high
standards of this text set into motion six editions ago.
• Craig L. Scanlan is the new coeditor of this project.
Dr. Scanlan is a Professor Emeritus at the University
of Medicine and Dentistry with over 40 years of experience in respiratory care. He was a coeditor for four
editions of Egan’s Fundamentals of Respiratory Care, two
in collaboration with Dr. Wilkins.
• Each chapter has been carefully updated to reflect the
latest standards of practice and credentialing exam
content.
• All chapters also have been peer reviewed, and the content is reflective of reviewer input and expertise.
• Revised chapter organization reflects a more logical progression of assessment.
• A greater emphasis on infection control throughout the
text highlights its continued importance across health
care.
• Enhanced chapters include Preparing for the Patient
Encounter, Fundamentals of Physical Assessment, Clinical Laboratory Studies, Cardiac Output Measurement,
Bronchoscopy, Respiratory Monitoring in Critical Care,
and Sleep and Breathing Assessment.


PREFACE

Features
We continue to use learning features to help guide the student to mastery of the content. This edition features the
following:
• Chapter outlines introduce students to chapter content
and progression to enhance note taking.
• Measurable chapter learning objectives help with mastery of information.
• Key terms are bolded and defined within the text to
enhance terminology comprehension.
• “Simply Stated” boxes are scattered throughout each
chapter to succinctly summarize and highlight key
points within the text.
• Bulleted “Key Points” at the end of each chapter emphasize the topics identified in the learning objectives and
provide the student with an overview of chapter content
for easy review.
• Select chapters include “Case Studies,” which feature realistic clinical scenarios for student practice and/or classroom discussion.
• “Questions to Ask” boxes are also included in select chapters. They provide lists of questions that practitioners
should ask when confronted with certain pathologies.
• “Assessment Questions” conclude each chapter to easily
assess understanding.

Learning Aids
Evolve Resources— http://evolve.elsevier.com/Heuer/Wilkins
Evolve is an interactive learning environment designed
to work in coordination with this text. Instructors may
use Evolve to provide an Internet-based course component that reinforces and expands the concepts presented
in class. Evolve may be used to publish the class syllabus, outlines, and lecture notes; set up “virtual office
hours” and e-mail communication; share important
dates and information through the online class calendar; and encourage student participation through chat

xi

rooms and discussion boards. Evolve allows instructors
to post examinations and manage their grade books
online.

For the Instructor
Evolve offers valuable resources to help instructors prepare their courses, including:
• A test bank of approximately 1000 questions in
ExamView
• An image collection of the figures from the book Comprehensive PowerPoint presentations for each chapter
• NBRC CRT/RRT Summary Content Outline Correlation Guide mapping the text to the content outlines

For Students
Evolve offers valuable resources to help students succeed
in their courses, including:
• Student Lecture Notes in PowerPoint format for students to print and take to lecture for enhanced note
taking
• NBRC CRT/RRT Summary Content Outline Correlation Guide mapping the text to the content outlines
For more information, visit http://evolve.elsevier.com/
Heuer/Wilkins/ or contact an Elsevier sales representative.

Acknowledgments
We wish to thank the previous editor, Dr. James Dexter,
for his many years of devotion to earlier editions of this
project. Without him, this book would not have become
the cornerstone text in respiratory patient assessment.
We also thank the new and returning contributors to the
chapters in this text. Their expertise, as well as their willingness and ability to share it, is most important to the
value of this text. Finally, we would like to thank the peer
reviewers, who provided invaluable and practical feedback
for all chapters, which has been appropriately reflected in
this edition.


Contents
1. P
 REPARING FOR THE PATIENT
ENCOUNTER, 1
Craig L. Scanlan

Cara Denunzio and Albert J. Heuer

Individualized Care, 2
Patient Involvement, 6
Provider Collaboration, 9

Examination of the Head and Neck, 76
Lung Topography, 78
Examination of the Thorax, 80
Examination of the Precordium, 93
Examination of the Abdomen, 96
Examination of the Extremities, 96

2. T
 HE MEDICAL HISTORY AND
THE INTERVIEW, 15
Albert J. Heuer
Patient Interview, 16
Cardiopulmonary History and Comprehensive
Health History, 18
Reviewing the Patient’s Medical Record, 28
Assessment Standards for Patients with Pulmonary
Dysfunction, 28

3. C
 ARDIOPULMONARY
SYMPTOMS, 32
Albert J. Heuer
Cough, 33
Sputum Production, 35
Hemoptysis, 36
Shortness of Breath (Dyspnea), 38
Chest Pain, 42
Dizziness and Fainting (Syncope), 47
Swelling of the Ankles (Dependent Edema), 48
Fever, Chills, and Night Sweats, 49
Headache, Altered Mental Status, and Personality
Changes, 51
Snoring and Daytime Somnolence (Sleepiness), 52
Gastroesophageal Reflux, 53

4. VITAL SIGNS, 56
Albert J. Heuer
Obtaining Vital Signs and Clinical Impression, 57
Frequency of Vital Signs Measurement, 58
Trends in the Vital Signs, 58
Comparing Vital Signs Information, 58
Height and Weight, 59
General Clinical Presentation, 59
Temperature, 61
Pulse, 64
Respiratory Rate and Pattern, 65
Blood Pressure, 66

xii

5. F
 UNDAMENTALS OF PHYSICAL
EXAMINATION, 73

6. NEUROLOGIC ASSESSMENT, 102
Ruben D. Restrepo and Zaza Cohen
Functional Neuroanatomy, 103
Assessment of Consciousness, 108
Cranial Nerve Examination, 111
Sensory Examination, 112
Motor Examination, 113
Deep Tendon, Superficial, and Brainstem
Reflexes, 114
Coordination, Balance, and Gait
Examination, 117
Vital Organ Function and the Neurologic
System, 118
Ancillary Testing of the Neurologic System, 122
Declaration of Brain Death, 123

7. C
 LINICAL LABORATORY
STUDIES, 126
Nadine A. Fydryszewski and Elaine
M. Keohane
Clinical Laboratory Overview, 127
Hematology, 128
Chemistry, 135
Microbiology, 141
Histology and Cytology, 144
Skin Testing, 145
Recommended Laboratory Tests, 146

8. INTERPRETATION OF BLOOD
GASES, 152
Craig L. Scanlan
Indications for Blood Gas and Oximetry
Analysis, 153
Sampling and Measurement, 153
Assessment of Oxygenation, 158
Assessment of Acid-Base Balance, 162
Simple Acid-Base Imbalances, 164


CONTENTS
Combined Acid-Base Disturbances, 167
Mixed Acid-Base Disturbances, 167
Assuring Valid Measurement and Use of Blood Gas
Data, 168
Systematic Interpretation of Blood Gases, 169

9. P
 ULMONARY FUNCTION
TESTING, 178
Craig L. Scanlan
Lung Volumes and Capacities, 179
Spirometry, 181
Static Lung Volumes, 188
Diffusing Capacity of the Lung (Dlco), 192
Specialized Tests, 194
Infection Control, 200

10. CHEST IMAGING, 207
Zaza Cohen
Production of the Radiograph, 208
Indications for the Chest Radiograph
Examination, 210
Radiographic Views, 210
Evaluation of the Chest Radiograph, 212
Clinical and Radiographic Findings in Lung
Diseases, 214
Postprocedural Chest Radiograph Evaluation, 222
Computed Tomography, 225
Magnetic Resonance Imaging, 227
Radionuclide Lung Scanning, 228
Positron Emission Tomography, 229
Pulmonary Angiography, 230
Chest Ultrasound, 230
Fluoroscopy, 230
Interventional Radiology, 230
Radiation Safety, 230

11. INTERPRETATION OF
ELECTROCARDIOGRAM
TRACINGS, 234
Albert J. Heuer
What Is an Electrocardiogram? 235
What Is the Value of an Electrocardigram? 235
When Should an Electrocardiogram
Be Obtained? 236
Cardiac Anatomy and Physiology, 236
Causes and Manifestations of Dysrhythmias, 239
Important Abbreviations and Acronyms, 240
Basic Electrocardiogram Waves, 240
Electrocardiogram Leads, 244
Steps of Electrocardiogram Interpretation, 247
Normal Sinus Rhythm, 248
Identification of Common Dysrhythmias, 248
Evidence of Cardiac Ischemia, Injury,
or Infarction, 257

Assessing Chest Pain, 259
Electrocardiogram Patterns with Chronic Lung
Disease, 259

12. N
 EONATAL AND PEDIATRIC
ASSESSMENT, 263
Narciso Rodriguez
Assessment of the Newborn, 264
Assessment of the Critically Ill Infant, 286
Assessment of the Older Infant and Child, 287

13. O
 LDER PATIENT
ASSESSMENT, 296
David Gourley
Patient-Clinician Interaction, 297
Age-Related Sensory Deficit, 298
Aging of the Organ Systems, 299
Patient Assessment, 302
Diagnostic Tests, 306
Comprehensive Geriatric Assessment, 309

14. R
 ESPIRATORY MONITORING IN
CRITICAL CARE, 314
David L. Vines
Ventilatory Assessment, 315
Evaluation of Oxygenation, 333
Monitoring Tissue Oxygen Delivery and
Utilization, 337

15. V
 ASCULAR PRESSURE
MONITORING, 348
Kenneth Miller and Craig L. Scanlan
Arterial Pressure Monitoring, 349
Central Venous Pressure Monitoring, 354
Pulmonary Artery Pressure Monitoring, 358
Central Line Bundle, 367

16. C
 ARDIAC OUTPUT
MEASUREMENT, 373
Ruben D. Restrepo
Cardiac Output, 374
Venous Return, 375
Measures of Cardiac Output and Pump
Function, 375
Determinants of Pump Function, 377
Methods of Measuring Cardiac Output, 383

17. BRONCHOSCOPY, 396
Zaza Cohen
Characteristics and Capabilities of the
Bronchoscope, 397

xiii


xiv

CONTENTS
Indications for Bronchoscopy, 400
Complications, 402
Outpatient Bronchoscopy, 403
Inpatient Bronchoscopy, 407
Role of the Respiratory Therapist, 407

18. NUTRITION ASSESSMENT, 410
Jane E. Ziegler
Malnutrition and the Pulmonary System, 411
Effect of Pulmonary Disease on Nutritional
Status, 412
Interdependence of Respiration and Nutrition, 412
Respiratory System and Nutritional Needs, 416
Metabolism, 418
Nutritional Requirements, 420
Methods of Meeting Nutritional Requirements, 424
Nutritional Assessment, 425
Role of the Respiratory Therapist in Nutritional
Assessment, 429

19. S
 LEEP AND BREATHING
ASSESSMENT, 436
Robert Allen and Albert J. Heuer
Normal Stages of Sleep, 437
Assessment of Sleep-Disordered Breathing, 440
Sleep-Disordered Breathing, 445

20. HOME CARE PATIENT
ASSESSMENT, 453
Albert J. Heuer
The Evolution and Importance of Respiratory
Home Care, 454
The Home Care Patient, 454
Home Care Assessment Tools and Resources, 455

Role and Qualifications of the Home Care
Respiratory Therapist, 456
Assessment and the Home Visit, 457

21. DOCUMENTATION, 468
David Gourley
General Purposes of Documentation, 469
The Joint Commission and Legal Aspects of the
Medical Record, 469
Types of Medical Records, 472
Organizing Patient Information, 473
Charting Methods, 476

APPENDIX: ASSESSMENT
QUESTIONS ANSWER KEY, 482
GLOSSARY, 486
INDEX, 497


Chapter

1

Preparing for the Patient Encounter
CRAIG L. SCANLAN*

CHAPTER OUTLINE
Individualized Care
Providing Empathetic Two-Way Communication
Respecting Patient Needs and Preferences
Assuring Privacy and Confidentiality
Being Sensitive to Cultural Values
Patient Involvement
Assessing Learning Needs and Providing Patient
Education

Sharing Goal-Setting and Decision-Making
Responsibilities
Encouraging Patient and Family Participation in
Care and Safety
Provider Collaboration
Enhancing Interprofessional Communication
Coordinating Patient Care
Sharing Responsibility

LEARNING OBJECTIVES
















After reading this chapter, you will be able to:
1.Define patient-centered care and identify its key elements.
2.Identify the major factors affecting communication between the patient and clinician.
3.Differentiate among the stages of the clinical encounter and the communication strategies appropriate
to each stage.
4.Incorporate patients’ needs and preferences into your assessment and care planning.
5.Apply concepts of personal space and territoriality to support patients’ privacy needs.
6.Employ basic rules to assure the confidentiality and security of all patient health information.
7.Identify the key abilities required for culturally competent communication with patients.
8.Specify ways to involve patients and their families in the provision of heath care.
9.Identify the steps in assessing a patient’s learning needs, including how to overcome any documented
barriers to learning.
10.Explain the use of patient action plans in facilitating goal setting and patient self-care.
11.Specify steps the patient and family can take to enhance safety and reduce medical errors.
12.Identify standard infection control procedures needed during patient encounters.
13.Outline ways to assure effective communication with other providers when receiving orders and
reporting on your patient’s clinical status.
14.Specify how to coordinate your patient’s care with that provided by others, as well as when transferring
responsibilities to others and planning for patient discharge.
15.Identify examples of how respiratory therapists can participate effectively as a team member to enhance
outcomes in caring for patient with both acute and chronic cardiopulmonary disorders.

KEY TERMS
action plan
culturally competent
communication
intimate space
nonverbal communication
patient-centered care

personal space
Protected Health Information
(PHI)
return demonstration
social space
SBAR

Speak Up initiative
standard precautions
teach-back method
territoriality

*Dr. Robert Wilkins, PhD, RRT, contributed much of the content for this chapter as the coeditor of the prior edition of this text.

1


CHAPTER 1 • Preparing for the Patient Encounter

2

D

uring the past decade, numerous governmental
agencies and private provider groups have concluded that meaningful improvements in health
care require a renewed focus on the interaction between
patient and provider. This new focus is termed patientcentered care.
Figure 1-1 depicts the three main elements underlying
patient-centered care: individualized care, patient involvement, and provider collaboration. Patient-centered care is
founded on a two-way partnership between providers and
patients (and their families) designed to ensure that (1)
the care given is consistent with each individual’s values,
needs, and preferences, and (2) patients become active participants in their own care. By improving communication
and creating more positive relationships between patients
and providers, patient-centered care can improve adherence to treatment plans and thus help achieve higherquality outcomes. In addition, patient-centered care can
help minimize medical errors and contribute to enhanced
patient safety.
The patient-provider encounter is at the heart of effective patient-centered care. Such encounters are so commonplace in the daily routine of the respiratory therapist
(RT) that we often forget how important these short interactions can be in determining the effectiveness of the care
we provide. To that end, this chapter focuses on how RTs
can use these encounters to promote high-quality care that
is attentive to the needs and expectations of each individual patient.

Individualized Care
Individualized care requires empathetic, two-way communication; respect for each patient’s values and privacy; and
sensitivity to cultural values.

Providing Empathetic Two-Way
Communication
Underlying patient-centered communication is empathetic and effective communication. Communication is
a two-way process that involves both sending and receiving meaningful messages. If the receiver does not fully understand the message, effective communication has not occurred. As

Individualized Care
Patient Involvement
Empathetic communication
Patient education
Respect for patient values/privacy
Shared decision-making
Sensitivity to cultural values
Patient participation in care
Provider Collaboration
Communication
Coordination
Shared responsibility

FIGURE 1-1  The essential elements of patient-centered care.

indicated in Figure 1-2, multiple personal and environmental factors influence the effectiveness of communication during clinical encounters. Attending to how each of
these components may affect communication can make
the difference between an effective and ineffective clinical
encounter.
Each party to a clinical encounter brings attitudes and
values developed by prior experiences, cultural heritage,
religious beliefs, level of education, and self-concept. These
personal factors affect the way a message is sent as well as
how it is interpreted and received. Messages can be sent
in a variety of ways and at times without awareness. Body
movement, facial expression, touch, and eye movement are
all types of nonverbal communication. Combined with
voice tone, nonverbal cues frequently say more than words.
Because one of the purposes of the encounter is to establish
a trusting relationship with the patient, the clinician must
make a conscious effort to send signals of genuine concern, that is, to exhibit compassion and empathize with the
patient’s circumstances. Techniques useful for this purpose
are facing the patient squarely, using appropriate eye contact, maintaining an open posture, using touch, and actively
listening. It also may be helpful to act according to what you
would expect from health care team members were you in
the patient’s situation (the “golden rule” of bedside care).
One of the most common mistakes made by clinicians
during patient encounters is failing to listen carefully to
the patient. Good listening skills require concentration
on the task at hand. Active listening also calls for replying
to the patient’s comments and questions with appropriate responses. Patients are quick to identify the clinician
who is not listening and will often interpret this as a lack of
empathy or concern. If the patient says something you do
not understand, it is best to ask the patient to clarify what
was said rather than replying with the response you think
is right. Asking for clarification tells the patient that you
want to make sure you get it right.
Messages are also altered by feelings, language differences, listening habits, comfort with the situation, and
preoccupation. Patients experiencing pain or difficulty
breathing will have a hard time concentrating on what you
are communicating until their comfort is restored. The
temperature, lighting, noise, and privacy of the environment also may contribute to comfort. Patients may communicate their discomfort nonverbally using cues such as
sighing, restlessness, looking into space, and avoiding eye
contact.
Your use of communication techniques may differ
according to the stage of interaction with a patient. Generally, a patient encounter begins with a chart review and
then progresses through four additional stages: introductory, initial assessment, treatment and monitoring, and
follow-up. Table 1-1 outlines the purpose of these stages
and provides example strategies to help ensure effective
communication during each major aspect of the patient
encounter.


Preparing for the Patient Encounter • CHAPTER 1

Respecting Patient Needs
and Preferences

3

The social space (4 to 12 feet) is used primarily in the
introductory stage of the encounter during which you
begin to establish rapport. At this distance, you can see
the “big picture” and gain an appreciation for the whole
patient and the patient’s environment. Vocalizations are
limited to the more formal issues, and personal questions
in this space are to be avoided because others in the room
may overhear the conversation.
The personal space (18 inches to 4 feet) is used primarily during the interview component of the initial assessment, usually after establishing rapport with the patient.
This enhanced proximity is generally needed to garner
sensitive patient information, such as questions about
daily sputum production or smoking habits. To better
assure privacy in this space, pulling the bedside curtain
may help the patient feel more comfortable about sharing personal information. Most patients also feel more
comfortable and confident when your appearance is neat,
clean, and professional. Patient trust can be enhanced by
assuring appropriate eye contact while in the patient’s
personal space.
Intimate space (0 to 18 inches) is reserved primarily for the physical examination component of the initial
assessment and the treatment and monitoring stage of
the encounter. Generally, moving into such proximity and
touching the patient should be done only after establishing rapport and being given permission to do so. Such
permission often is obtained by simply requesting consent
to listen to breath sounds or check vital signs. Asking permission to move into the intimate space communicates
both your respect for patient privacy and your willingness
to share responsibility for decision making. Minimal eye
contact is used in this space. Verbal communication with the
patient should be limited to simple questions or brief commands, such as, “Please take a deep breath.”

In addition to effective communication, individualized
care requires that providers respect each patient’s needs,
preferences, and privacy. Within this framework, we do not,
for example, treat “the COPD patient in room 345,” but a
patient with COPD, whose ability to cope with its full range of
physical and psychosocial consequences is unique. Indeed,
effective therapy requires that the individual patient’s
response to disease be ascertained as part of the initial
patient encounter and, for those with chronic afflictions,
be regularly assessed and incorporated into care plans.
Whenever possible, care plans also should reflect each
individual patient’s preferences as determined during initial assessment and treatment. For example, after their
urgent situation is resolved, patients with asthma should
be allowed to participate in deciding which aerosol drug
delivery system is best for them. Likewise, a patient with
cystic fibrosis should be allowed to participate in selecting
from a variety of equally effective positive-­pressure devices
to assist in airway clearance. Accommodating an individual’s needs during treatment also involves modifying the
therapy based on the patient’s response.

Assuring Privacy and Confidentiality
Anyone who has been hospitalized understands the need
for privacy. We address privacy concerns in part by respecting personal space. Respecting patients’ privacy rights
is both a legal and a moral obligation for health care
professionals.
To respect patients’ personal space, one needs to understand both the general and cultural implications of proximity and direct contact. Figure 1-3 depicts the three zones
of space commonly associated with the bedside patient
encounter.
INTERNAL FACTORS

SENSORY/EMOTIONAL FACTORS

INTERNAL FACTORS

Previous experiences
Attitudes, values
Cultural heritage
Religious beliefs
Self-concept
Listening habits
Preoccupations, feelings

Fear
Stress, anxiety
Pain
Mental acuity, brain damage, hypoxia
Sight, hearing, speech impairment

Previous experiences
Attitudes, values
Cultural heritage
Religious beliefs
Self-concept
Listening habits
Preoccupations, feelings
Illness

ENVIRONMENTAL FACTORS
Lighting
Noise
Privacy
Distance
Temperature
VERBAL EXPRESSION

NONVERBAL EXPRESSION

Language barrier
Jargon
Choice of words/questions
Feedback, voice tone

Body movement
Facial expression
Dress, professionalism
Warmth, interest

FIGURE 1-2  Factors influencing the effectiveness of communication during clinical encounters.


CHAPTER 1 • Preparing for the Patient Encounter

4

TABLE 1-1
Stages of the Clinical Encounter
Stage
Purpose
Chart review
(preinteraction)
Introductory

Initial assessment

Treatment and
monitoring

Follow-up

Communication Strategies

Identifying key patient information

Apply this information in the introductory and initial
assessment stages
Look and act in professional manner
Introducing oneself
Refer to patient using formal last name
Confirming patient identity
Avoid encroaching on personal space
Clarifying purpose/your role
Pay attention to nonverbal cues
Acknowledging family presence
Identify patient emotions
Building rapport
Express support and empathy (compassion)
Inspecting the patient (initial)
React in nonjudgmental way
Determining patient’s status (interview and
Use active listening:
physical examination)
•Avoid interrupting the patient
Determining learning needs
•Use body position to indicate interest
Assessing cultural differences
•Avoid writing while patient is talking
Determining appropriateness of orders (new Rx) •Make eye contact but do not stare
•Encourage open expression
Reflect what the patient shares
Summarize/request feedback
Make facilitative responses, e.g., nodding
Demonstrating/teaching treatment technique
Explain therapy in understandable terms
Implementing and modifying treatment based
Invite questions about the treatment
on patient’s preferences, monitored responses Confirm acceptance of the treatment
Assess patient’s concerns, expectations
Attend to patient discomfort
Confirming patient response
Invite questions from patient and family
Developing shared goals
Determine information preferences
Assuring follow-up
Check the patient’s ability to follow the plan
Restoring environment
Discuss follow-up (e.g., treatment schedule, what to do if
symptoms worsen)

Be aware that some patients may respond poorly to
encroachment into their space. Gender, age, race, physical appearance, health status, and cultural background
are among the many factors that may influence a patient’s
comfort level when you enter the intimate space. Should
the patient’s words or nonverbal responses indicate hesitancy with your actions, be prepared to move more slowly
and communicate your intent very carefully.
Related to the concept of proximity is that of territoriality. Most patients “lay claim” to all items within a certain
boundary around their bed. For patients in a private room,
the boundary extends to the walls of the room. Removing
items from the patient’s “territory” should occur only after
permission has been obtained. For example, when borrowing a chair from the bedside of Mr. Jones for use at the bedside of Mr. Smith, you should ask Mr. Jones for permission.
Likewise, at the end of the patient encounter, be sure to
replace any items temporarily removed from the patient’s
territory, such as the over-the-bed table and its essential
contents.

SIMPLY STATED
The social space (4 to 12 feet) is for introductions, the
personal space (18 inches to 4 feet) is for interviewing,
and the intimate space (0 to 18 inches) is for physical
examination.

In regard to maintaining confidentiality, all health professionals become privy to sensitive patient information.
For example, your chart review may reveal that a patient
under your care has a history of drug abuse or has been
diagnosed with a sexually transmitted disease. This information is private and not for public knowledge. You have
both a legal and a moral obligation to keep this information in strictest confidence and share it only with other
health professionals who have a need to know, such as the
patient’s nurse or attending physician. Most often, violations of patient confidentiality occur in public spaces when
a clinician discusses a certain patient with other caregivers
while being overheard by visitors. A good basic rule to follow is to discuss your patient’s health status only with other members of the health care team who need to know such information
and only in a private area where visitors are not allowed.
Family members and visitors often ask questions about
the patient’s diagnosis but always should be referred to
the attending physician. This should be done in a way that
does not alarm or offend those asking the questions. Most
people will appreciate an honest response in which you tell
them that privacy rights prevent you from discussing the
patient’s diagnosis with others.
Your legal obligations regarding patient information are specified under the privacy and security rules of
the Health Insurance Portability and Accountability Act
(HIPAA). These rules establish regulations for the use


Preparing for the Patient Encounter • CHAPTER 1
18 in.

4 ft.

5

12 ft.

Intimate Space

Personal Space

Social Space

Physical exam

Interview

Introduction

FIGURE 1-3  Illustration of the social, personal, and intimate spaces characterizing the clinical encounter.

and disclosure of Protected Health Information (PHI).
PHI is any information about health status, provision of
health care, or payment for health care services that can be
linked to an individual. Examples of PHI include names
and addresses, phone numbers, e-mail addresses, Social
Security and medical record numbers, and health insurance information. Under the law, patients control access
to their PHI. For this reason, use or disclosure of PHI for
purposes other than treatment, payment, health care operations, or public health requires patient permission. Table
1-2 provides summary guidance on key privacy and security considerations under HIPAA.

Being Sensitive to Cultural Values
As already mentioned, individualized care requires that
clinicians be sensitive to their patients’ cultural values
and expectations. To achieve a full partnership with your
patient, you’ll need to identify and respond appropriately to the many cultural cues that can affect the clinical
encounter and thus the success of therapy. Failure to do
so can result in patient dissatisfaction, poor adherence to
treatment regimens, and unsatisfactory health outcomes.
In the past, clinicians were expected to learn about
the cultural norms of each and every ethnic group they
would likely encounter. Certainly some knowledge about
specific cultural issues is helpful and tends to grow with

TABLE 1-2
HIPAA-Related Privacy and Security Considerations
Do’s
Don’ts
Do access only that
information needed to
perform your job
Do keep voices low when
discussing patient issues in
joint treatment areas
Do provide only the minimal
needed information on
request
Do position workstations so
that the screens are not
visible to prying eyes
Do keep patient information
on whiteboards to a
minimum
Do place fax machines used
to receive PHI in secure
locations

Don’t discuss a patient’s PHI
with people with no need to
know
Don’t share your computer
passwords and log-on
information
Don’t leave a computer
unattended without
logging off
Don’t discuss a patient’s PHI
in public settings where you
can be overheard
Don’t communicate PHI by
methods that the patient has
not approved
Don’t leave a patient’s paper
records open and available
for prying eyes

experience. One should over time aim to achieve at least a
basic understanding of various cultures’ beliefs. Realistically however, the growing diversity of the U.S. population
makes it impossible to master all the nuances characterizing the many cultures now represented. Instead, one


6

CHAPTER 1 • Preparing for the Patient Encounter

needs to develop culturally competent communication
skills.
Culturally competent communication is founded on
the same basic strategies underlying empathetic and caring
patient interaction, that is, active listening, attending to
individual needs, eliciting patient concerns, and expressing
genuine concern. Ideally, the RT should apply these strategies during the initial assessment stage of the encounter
to briefly explore the patient’s key cultural beliefs, especially those related to gender and family roles, responses to
authority, personal space, religious values, and concepts of
health and disease. For example, in some cultures it is normal to always defer to the authority of a doctor or health
care professional when deciding what is best so that efforts
to involve the patient in decision making may be difficult.
Likewise, patients who believe that fate determines disease
outcomes may be reluctant to participate in their own care.
Reflecting on what the patient shares in a nonjudgmental way can help further the development of rapport and
enhance one’s ability to adapt to cultural differences.
Complementing the use of general communication
skills are three additional abilities that can enhance one’s
cultural competence: self-awareness, situational awareness, and adaptability. Self-awareness involves knowledge
of one’s own cultural beliefs as well as any potential stereotypes one might hold about particular groups. By being
self-aware, you can recognize in advance possible cultural
prejudices or emotions you might have toward certain
patients and thus negate their impact on the care you provide. Situational awareness is the ability to recognize misunderstandings associated with patient-provider cultural
differences as they occur during a patient encounter. For
example, a woman who is constantly looking toward her
husband for approval during a clinical interaction may be
signaling a cultural tendency to defer to the man for all
major decision making. Once such cues are recognized, the
culturally competent clinician should be able to adapt to
the specific situation by individualizing the communication approach in a manner consistent with the patient’s
(and family’s) values and beliefs. In this case, one might
consider reorienting the encounter by making the husband a major partner into the conversation.
SIMPLY STATED
During the assessment component of the clinical encounter,
you should explore your patient’s key cultural beliefs and
use this knowledge to adapt your communication to the
patient’s and family’s values and beliefs.

Patient Involvement
Patient-centered care is a two-way street. As such, tailoring care to the individual is not enough. To be successful,
patient-centered care must involve the patient and family
as partners in setting goals, making decisions, participating

in the treatment regimen, providing appropriate self-care,
and helping assure safety. To meet these expectations,
patients—especially those with chronic conditions—must
understand the basics about their disease process and how
to effectively manage it. This level of involvement can only
occur when the clinician incorporates needed educational
activities into each clinical encounter.

Assessing Learning Needs and
Providing Patient Education
Patient and caregiver education aims to foster healthy
behaviors and increase patients’ involvement in their health
care and safety, with the end goal being satisfaction of both
patient and provider with the outcomes. Although full
achievement of this goal requires a comprehensive, interdisciplinary approach, RTs can play a key role in improving
outcomes by providing appropriate patient education.
The first step in patient education is to assess the
patient’s learning needs. In most hospitals, the initial
assessment of learning needs is conducted by nursing staff,
occurs after the patient is admitted to a care unit, and is
documented in the patient’s chart. For this reason, during your chart review, you should access and evaluate this
record for any important information helpful in planning
the respiratory care of your patient.
SIMPLY STATED
Effective respiratory care requires a knowledgeable patient
willing and able to participate in treatment, for which
patient education is a prerequisite. The first step in patient
education is to assess the patient’s learning needs.

More often than not, you will need to briefly conduct
your own assessment, with a focus on learning needs specific to the patient’s disorder and the planned therapy. In
general, a learning needs assessment progresses through
the following key steps:
1.Identifying and accommodating barriers to patient
learning
2.Assessing the patient’s preferred learning method
3.Evaluating the patient’s readiness to learn
4.Determining the patient’s specific learning needs
Table 1-3 identifies several of the barriers to learning
commonly encountered by RTs in the clinical setting as
well as various ways to accommodate them.
To assess a patient’s preferred way of learning, first
observe the environment for clues such as the presence of
reading materials, use of television, or (for children) use
of toys and games. You also should ask the patient about
any recent learning efforts. Sometimes, preferred methods
of learning can be determined from questions about the
patient’s work or hobbies.
Evaluating the patient’s readiness to learn is the next
step in assessing learning needs. Patients’ spontaneous
questions about their condition, its management, or their


Preparing for the Patient Encounter • CHAPTER 1
TABLE 1-3



Barriers to Learning and Their Accommodation
Barrier to Learning
Accommodation
Age (young child)

Reduced level of
consciousness
Presence of pain
Presence of anxiety

Physical limitations

Educational level (low)

Potential language barrier
Cultural or religious
factors
Vision difficulty
Hearing difficulty

Keep teaching/learning episodes
short
Use fun-and-games approach
Enlist family assistance
Postpone until patient becomes
alert
Apply methods that don’t require
cooperation
Recommend analgesia
Postpone until pain management
is effective
Take time to calm the patient and
explain your actions
Postpone until anxiety
management is effective
Enlist family assistance
Recommend anxiolytic therapy
Ascertain specific limitations
Apply methods that circumvent
limitation
Enlist family assistance
Emphasize oral (vs. written)
instruction
Adjust language level as
appropriate
Provide written materials at fifthto eighth-grade level
Enlist family assistance
Secure translator
Ascertain key factors affecting care
Modify to accommodate
Enlist family assistance
Have patient wear glasses
Emphasize sound and touch
Enlist family assistance
Speak slowly and clearly while
facing the patient
Have patient use hearing aid
Emphasize visualization and touch
Enlist family assistance

From Scanlan CL, Heuer AJ, Sinopoli L: Certified respiratory therapist
exam review guide, Sudbury, MA: Jones & Bartlett Learning; 2009.
(www.jblearning.com). Reprinted with permission.

respiratory care indicate a desire to learn, as do expressions
of discomfort with their current abilities or situation.
After you have addressed any barriers to learning and
confirmed the patient’s desire to progress, you should
determine what the patient knows about the care you will
provide. To do so, you’ll need to ask pertinent questions,
using terms and language appropriate to the patient’s level
of understanding. Questions in this phase of the assessment need to address the following patient capabilities:
• Understanding of the current condition or disease
process
• Knowledge of prescribed medications
• Familiarity with the procedures you will implement
• Familiarity with the equipment you plan to use

Box 1-1

7

  Example Questions Assessing
a Patient’s Knowledge about a
Medication

Which medicine are you currently taking? How often?
Do you know why you are taking this medicine?
Who is responsible for administering the medicine?
Please show me how you take the medicine.
How many times a week do you miss taking the medicine?
What problems have you had taking the medicine (cost, time,
lack of need)?
What concerns do you have about your medicine?

Box 1-1 provides example questions focusing on a
patient’s knowledge about a prescribed medication.
If any of the patient’s answers indicates a shortcoming
in knowledge, you have identified a specific learning need.
In addition to assessing needs, you also should focus on
determining “wants,” that is, anything the patient wishes
to learn more about. Together, these needs and wants
can help establish education goals acceptable to both the
patient and family.
After conducting any learning activity, you should evaluate the results. To evaluate a desired change in knowledge,
have the patients repeat in their own words the information you are trying to get them to understand (the teachback method). On the other hand, to confirm that your
patients have learned how to perform a particular skill,
have them provide you with a return demonstration, that
is, going through the motions of the procedure after you
have shown it to them.

Sharing Goal-Setting and DecisionMaking Responsibilities
Effective patient education is a prerequisite to shared responsibility for goal setting and decision making. All key decisions
regarding patient management and the degree to which a
patient partners in that process are made by the attending
physician. In this regard, good communication between the
RT and the patient’s physician is essential. Ideally, a knowledgeable physician will give you the latitude needed not only
to assess learning needs but also to help the patient set tangible goals related to the care you provide. Such goals may be
as simple as achieving a targeted inspiratory capacity after
abdominal surgery or as complex as reaching agreement
with the patient on an action plan for routine self-care of
asthma and proper management of its exacerbations.
Written action plans are a particularly useful tool for
involving patients in goal-setting and self-care activities.
Action plan goals should be SMART, that is, specific, measurable, action oriented, realistic, and time limited. The
action plan itself should address the following elements:
• Exactly what is the goal?
• How will the goal be achieved (e.g., how, how much, how
often)?
• What barriers might prevent achieving the goal?


8


CHAPTER 1 • Preparing for the Patient Encounter
Box 1-2

  Example Action Plan Developed by a
Patient with Asthma

ACTION PLAN
1.Goals (something you want to do): cut school absences in
half
How: make sure I take my controller medicine as
prescribed; avoid my triggers (pet hair and tobacco
smoke); monitor my symptoms (cough, wheeze, chest
tightness, shortness of breath); take my reliever if
symptoms develop/worsen
Where: administer meds at home (controller) and at
home/school if reliever is needed
What: controller: Pulmicort Flexhaler (b.i.d.); reliever:
Proventil canister
When: Pulmicort: am/pm; Proventil puffs as needed;
monitor symptoms
Frequency: medications as prescribed; symptom
monitoring daily using diary
2.Barriers: many friends smoke or have house pets; hate
diary keeping
3.Plans to overcome barriers: avoid spending time indoors
with smokers or pets; use Twitter to keep my diary entries
4.Conviction: 7/10 (being pushed by parents!); confidence:
9 (I’m stubborn)
5.Follow-up: track absences for the coming semester (goal
is less than 5)



Box 1-3

  Speak Up: Help Prevent Errors
in Your Care

Everyone has a role in making health care safe. The joint
Commission’s Speak Up™ program gives simple advice on how
you can help make health care a good experience. Research
shows that patients who take part in decisions about their own
health care are more likely to get better faster. To help prevent
health care mistakes, patients are urged to “Speak Up.”
S | Speak up if you have questions or concerns. If you still
don’t understand, ask again. It’s your body and you have a
right to know.
P | Pay attention to the care you get. Always make sure
you’re getting the right treatments and medicines by the
right health care professionals. Don’t assume anything.
E | Educate yourself about your illness. Learn about the
medical tests you get, and your treatment plan.
A | Ask a trusted family member or friend to be your
advocate (advisor or supporter).
K | Know what medicines you take and why you take them.
medicine errors are the most common health care mistakes.
U | Use a hospital, clinic, surgery center, or other type of
health care organization that has been carefully checked out.
For example, The Joint Commission visits hospitals to see if
they are meeting The Joint Commission’s quality standards.
P | Participate in all decisions about your treatment. You are
the center of the health care team.
The Joint Commission, Oakbrook Terrace, III., www.jointcommission
.org/speakup.aspx

• How can the anticipated barriers be overcome?
• By what mechanism will follow-up occur?
• How much confidence does the patient have in achieving

the goal?
Box 1-2 provides an example of a simple action plan
for an adolescent with moderate asthma who has a recent
history of exacerbations causing frequent absences from
school.

Encouraging Patient and Family
Participation in Care and Safety
Joint goal setting provides the basis for greater patient
and family involvement in treatment regimens and, for
those with chronic conditions, ongoing self-care. Given
that the effectiveness of most respiratory care treatments requires patient cooperation and follow-through,
you need to constantly reiterate how better participation can result in better outcomes. A case in point is the
daily tracking of symptoms that the patient with asthma
included in her action plan (see Box 1-2). A good example
for an acute care patient with cystic fibrosis would be
monitoring sputum production after self-administered
positive airway pressure therapy. Regarding involving
the family, there is no better illustration than preparing
a patient requiring long-term mechanical ventilation for
discharge to home.
Involvement of the patient and family in care delivery
also has been shown to enhance safety and reduce medical

errors. The joint Commission’s “Speak Up” initiative provides excellent guidance in this regard. Box 1-3 provides
a summary of the key guidance this initiative provides to
patients, using the “Speak Up” acronym. Although most
hospitals orient patients upon admission to their role in
helping assure safety, respiratory therapists should use the
clinical encounter to reinforce this important role.
To further promote infection control, you should
instruct all patients, family members, and visitors with
signs or symptoms of a respiratory infection to follow the
Centers for Disease Control and Prevention (CDC) guidance on respiratory hygiene and cough etiquette:
• Covering the nose and mouth when coughing or
sneezing
• Using tissues to contain respiratory secretions
• Disposing of tissues in the nearest hands-free waste
receptacle after use

SIMPLY STATED
Involvement of the patient and family in care delivery
enhances safety and reduces medical errors. Respiratory
therapists should orient patients and their families to
their role in helping assure safety using strategies like The
Joint Commission Speak Up initiative and sharing the CDC
guidance on respiratory hygiene and cough etiquette.


Preparing for the Patient Encounter • CHAPTER 1

















Box 1-4

9

  CDC Standard Precautions

HAND HYGIENE
Always perform hand hygiene in the following situations:
• Before touching a patient, even if gloves will be worn
• After contact with a patient and before leaving the patient care area
• After contact with blood, body fluids, excretions, or wound dressings
• Before performing an aseptic task (e.g., accessing a vascular port)
• Whenever hands move from a contaminated body area to a clean area
• After glove removal
GLOVES
Wear gloves when there is potential contact with blood, body fluids, mucous membranes, nonintact skin, or contaminated equipment
• Wear gloves that fit appropriately (select gloves according to hand size)
• Do not wear the same pair of gloves for the care of more than one patient
• Do not wash gloves for the purpose of reuse
• Perform hand hygiene before and immediately after removing gloves
GOWNS
Wear a gown to protect skin and clothing during procedures or activities in which contact with blood or body fluids is anticipated.
• Do not wear the same gown for the care of more than one patient
• Remove gown and perform hand hygiene before leaving the patient’s environment (e.g., examination room)
FACEMASKS, EYE PROTECTION, RESPIRATORS
Use a facemask during patient care activities likely to generate splashes or sprays of blood, body fluids, or secretions—especially during
airway suctioning (using a standard catheter), endotracheal intubation, catheter insertion, and encounters with any patient under
droplet precautions.
Personal eyeglasses and contact lenses do not provide adequate eye protection
Use goggles with facemasks, or face shield alone, to protect the mouth, nose, and eyes
Wear an N95 or higher respirator when there is potential exposure to infectious agents transmitted by the airborne route (e.g.,
tuberculosis)









SOILED PATIENT CARE EQUIPMENT
Handle in a manner to prevent contact with skin or mucous membranes and to prevent contamination of clothing or the environment.
• Wear gloves if equipment is visibly contaminated
• Perform hand hygiene after handling
NEEDLES AND OTHER SHARPS
• Do not recap, bend, break, or hand-manipulate used needles
• If recapping is required, use a one-handed scoop technique only
• Use safety features when available
• Place used sharps in puncture-resistant container
PATIENT RESUSCITATION
• Use mouthpiece with one-way valve, resuscitation bag, other ventilation devices to prevent contact with mouth and oral
secretions (Centers for Disease Control and Prevention. http://cdc.gov.)

• Performing hand hygiene after contacting secretions or

contaminated objects
Safety demands that clinicians themselves also implement infection control procedures before, during, and after
all patient encounters. At a minimum, this involves application of standard precautions, as outlined in Box  1-4.
Good hand hygiene is the single most important element
in preventing spread of infection. Alcohol-based rubs are
the preferred method, except when either one’s hands
become visibly soiled with dirt, blood, or body fluids, or
when caring for patients with infectious diarrhea (e.g., Clostridium difficile, norovirus). In these cases, one should proceed with a vigorous soap and water handwashing for at
least 15 seconds.

Provider Collaboration
During the course of a hospital stay, a patient may interact with dozens of health care providers. Quality patientcentered care requires that these providers work together as
a team. When health care professionals fail to collaborate
effectively, patient safety is put at risk. Ineffective provider
collaboration also can result in increased length of stay,
wasted resources, and less than optimal patient outcomes.
Collaboration occurs when health care providers
assume complementary roles and cooperatively work
together, sharing responsibility for patient care. Unfortunately, many RTs function more as “lone rangers” than
as integral players on the health care team. To maximize


10

CHAPTER 1 • Preparing for the Patient Encounter

their impact on patient outcomes, RTs must better integrate their services with those of other providers. To do
so requires enhanced interprofessional communication,
interdisciplinary coordination, and better sharing of
responsibilities.

Enhancing Interprofessional
Communication
The Joint Commission defines effective communication
as being timely, accurate, complete, unambiguous, and
understood by the recipient. Because good interprofessional communication is essential to quality care, all RTs
must exhibit these skills. Such skills are particularly important when receiving orders, coordinating the patient’s care,
reporting the patient’s clinical status, and helping plan for
patient discharge.
Often, a clinical encounter begins with receipt of an
order from an authorized health care provider, most often
a physician, physician’s assistant, or nurse practitioner.
You cannot accept orders transmitted to you by unauthorized third parties, such as registered nurses. If an order is
transmitted to you by a third party, you must verify the
order in the patient’s chart before proceeding. If the order
is transmitted orally and you are authorized to take it, you
must avoid communication errors. The following actions
should be taken to avoid such errors:
• Record the complete order in the chart as it is being
transmitted.
• Read the order back to the originator exactly as written
and clarify as needed.
• Have the originator confirm the accuracy of the order as
read back.
• Time and date the order with the name and credentials
of the originator, specify “read back and confirmed,” and
provide your signature and credentials.
Regardless of their source or route of transmission, all
respiratory care orders must be verified as accurate and
complete. Should any element of an order be missing or
unclear, you must contact the prescriber for clarification
before implementing the request. The same procedure
applies if the order falls outside one’s institutional standards. For example, if the order specifies an abnormally
high drug dosage or includes a ventilator setting not normally applied in similar cases, you should contact the
prescriber and request an explanation before proceeding.
More detail on standards for order writing and order taking is provided in Chapter 21.
After most patient encounters, you will need to communicate your findings to other members of the health
care team. Written documentation in the patient’s chart
may suffice if the patient is stable after routine treatment.
However, whenever a patient’s condition changes or a procedure is poorly tolerated, in addition to providing written documentation, you must communicate your findings
orally to the patient’s nurse and physician. In this case,
your chart documentation should include not only your

findings but also who was notified about the change in the
patient’s condition.
For example, on entering the room of Mr. Jones to provide treatment for his asthma, you note that he appears
much more short of breath than usual. The treatment you
give him does not appear to help. It is imperative that you
document and communicate your findings. Oral discussion with the patient’s nurse is a good place to start. Notifying the patient’s physician of the change in Mr. Jones’
condition may also be appropriate in such cases. Next, you
must document the patient’s condition in his chart and
note whom you communicated with about the patient and
what was said. If there is evidence of deteriorating vital
signs, you should call the Medical Emergency or Rapid
Response Team and support the patient until the team
arrives.
SIMPLY STATED
Whenever you observe a change in a patient’s condition,
note your observations in the chart, orally report your
findings to the patient’s nurse, and document in writing
whom you notified about the situation.

Coordinating Patient Care
RTs also need to help coordinate their patients’ care. To
do so, you need to communicate with the patient’s nurse
or attending physician to schedule therapy at times least
likely to conflict with other essential patient activity and
most likely to coincide with any relevant drug regimen. For
example, you would avoid performing postural drainage
on a postoperative patient immediately after a meal but
would instead schedule this encounter after administration of pain medication. Likewise, you would communicate with nursing to ensure that before implementing a
ventilator weaning trial, all sedatives have been held back
from the patient.
Another key aspect related to good communication and
coordinating patient care is the patient “hand-off.” Common patient hand-offs occur when delivering a patient
to or receiving a patient from a care unit or diagnostic
facility, when providing patient reports at shift change,
or when having a colleague take over in an emergency
situation. Ideally, communication during such hand-offs
should be short but precise, providing the essential information needed by the recipient. One popular method for
standardizing these brief episodes is the SBAR format.
When using this format, communication about your
patient should address the following four essential elements: situation, background, assessment, recommendation. The same format also can be used when making
recommendations to the patient’s physician for a change
in therapy or when documenting a patient encounter in
the medical record. Chapter 21 provides more detail on
the appropriate use of this communication tool, including an example.


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