Patient assessment is a cornerstone of respiratory therapy and a critical section of the TMC Exam. This topic evaluates your ability to gather and interpret clinical data, identify abnormal findings, and recommend appropriate interventions.
A thorough understanding of patient assessment techniques is essential for delivering high-quality care and making accurate clinical decisions.
In this guide, we’ll provide you with practical tips and strategies to help you confidently tackle the patient assessment section of the TMC Exam, bringing you one step closer to earning your RRT credentials.
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Patient Assessment Tips for the TMC Exam
- Know how to interpret vital signs
- Understand abnormal breath sounds
- Understand abnormal breathing patterns
- Master chest percussion notes
- Know when to recommend a chest x-ray
Watch this video or keep reading to learn essential tips and tricks for mastering the patient assessment section of the TMC Exam.
1. Know How to Interpret Vital Signs
Understanding how to interpret a patient’s vital signs is crucial for passing the TMC Exam. You can expect to encounter multiple questions where vital signs are presented, and your ability to analyze and apply that information will determine your success.
Let’s consider a typical question you might see on the exam:
Example Question
A 58-year-old male in the ICU recently had a chest tube inserted to drain fluid from a pleural effusion. He is receiving mechanical ventilation with basic settings and displays the following vital signs:
- Heart rate: 120/min
- Blood pressure: 137/95 mmHg
- Set respiratory rate: 10/min
- Total respiratory rate: 29/min
- Body temperature: 99.2°F
Taking everything into consideration, which of the following would you recommend?
A. Assess the patient for pain
B. Administer a paralytic agent
C. Ask the patient to relax
D. Reposition the chest tube
Explanation
To get this question right, you need to analyze the vital signs and consider the clinical context. Let’s break it down:
- The heart rate is elevated at 120/min (i.e., tachycardia).
- The total respiratory rate is significantly higher than the set rate, indicating the patient is breathing over the ventilator settings.
- The blood pressure is also elevated at 137/95 mmHg (i.e., hypertension).
These signs suggest that the patient is in distress. Since the patient is postoperative and had an invasive procedure (chest tube insertion), pain is a highly likely cause of these abnormal vital signs. Because the patient is on a ventilator, they may not be able to verbally communicate their discomfort.
Assessing the patient for pain is the most appropriate response given the vital signs and clinical context. Pain can increase heart rate, respiratory rate, and blood pressure, making it the primary issue to address.
Paralytics are used for patient-ventilator asynchrony but do not treat pain. This would not be appropriate in this scenario. If the patient is in pain, simply asking them to relax will not alleviate their symptoms. Chest tube repositioning is only considered if there is an indication of tube malposition (e.g., air leaks or drainage issues), and should not be done without first obtaining a chest x-ray.
Correct Answer: A. Assess the patient for pain
Key Takeaway for the TMC Exam
You will encounter questions where vital signs are presented to assess the patient’s status. Your ability to interpret these values and apply what you know about patient care is essential. When analyzing vital signs:
- Identify Trends: Look for patterns such as tachycardia, tachypnea, or hypertension that indicate stress, pain, or other complications.
- Consider the Clinical Context: Postoperative patients are more likely to experience pain or anxiety, which can cause elevated vital signs.
- Rule Out Inappropriate Options: If the answer choices involve interventions unrelated to the underlying issue, eliminate them systematically.
Note: By mastering these skills, you’ll be better equipped to handle questions that require vital sign interpretation on the TMC Exam, bringing you closer to earning your RRT credential.
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2. Understand Abnormal Breath Sounds
Mastering the different types of abnormal breath sounds is crucial for passing the TMC Exam. Many questions will incorporate these sounds into scenarios, requiring you to identify the underlying issue and recommend the appropriate treatment.
Here’s a comprehensive guide to help you remember and understand the key abnormal breath sounds you’ll encounter:
Wheezing
Wheezes are high-pitched whistling sounds that occur as air flows through a narrowed airway. They can be heard during both inspiration and expiration, but are more prominent during expiration.
Common Causes and Treatments:
- Bilateral Wheezing: Indicates bronchoconstriction (e.g., asthma or COPD exacerbation) and should be treated with a short-acting bronchodilator (e.g., albuterol).
- Unilateral Wheezing: Typically caused by a foreign body obstruction in one lung, which requires a bronchoscopy to remove the obstruction.
- Wheezing with Fluid Overload: Seen in patients with CHF or pulmonary edema and must be treated with diuretic therapy (e.g., Lasix).
Crackles (Rales)
Crackles are short, explosive sounds heard in the small or middle airways. They are caused by fluid or secretions in the lungs and can be heard during inspiration and expiration but are more common during the inspiratory phase.
Types and Indications:
- Fine Crackles: High-frequency, short-duration sounds. They are associated with fluid in the smaller airways, commonly seen in CHF and pulmonary edema. Treatment requires diuretics to reduce fluid buildup.
- Coarse Crackles (Rhonchi): Low-pitched, longer-duration sounds caused by secretions in the larger airways. They are associated with conditions that increase mucus production, such as bronchitis or pneumonia. Treatment requires bronchial hygiene therapy or suctioning.
Bronchial Breath Sounds
Bronchial breath sounds are hollow, tubular sounds that are normal when heard over the trachea but abnormal when heard over the lung fields. When heard over the lung fields, it suggests that air is moving through dense lung tissue, which is a sign of abnormal lung pathology.
Note: For the TMC Exam, remember that if bronchial breath sounds are heard over the lungs, it’s often a sign of pneumonia and indicates consolidation.
Stridor
Stridor is a high-pitched, harsh sound heard during inspiration when an upper airway obstruction is present. This breath sound is a medical emergency that requires immediate attention. Common causes of stridor include:
- Croup
- Epiglottitis
- Post-Extubation Laryngeal Edema
- Foreign Body Aspiration
Treatment typically requires cool mist therapy and racemic epinephrine to reduce airway swelling.
In severe cases, intubation and mechanical ventilation may be necessary to secure the airway.
Pleural Friction Rub
A pleural friction rub is a grating, creaking sound heard over the lungs when the pleural layers are inflamed and rub together. This occurs when there is decreased pleural fluid in the pleural space and is commonly associated with pleurisy or pleuritis.
Key Post-Intubation Auscultation Tip
If you notice that breath sounds are absent on the left side immediately after intubation, it’s a sign of right mainstem intubation. This occurs when the ET tube is inserted too far and slips into the right bronchus, leaving the left lung unventilated.
In this case, you must withdraw the ET tube by 1–2 cm and reassess breath sounds to ensure that both lungs are being ventilated effectively.
Summary of Key Exam Points
- Wheezing: High-pitched sound due to airway narrowing. Determine if it’s bilateral (bronchoconstriction) or unilateral (foreign body).
- Crackles (Rales): Short, popping sounds associated with fluid or secretions. Fine crackles = small airways (CHF); coarse crackles = large airways (mucus).
- Bronchial Sounds: Normal over the trachea, but abnormal over the lung fields (pneumonia).
- Stridor: High-pitched sound due to upper airway obstruction (medical emergency).
- Pleural Friction Rub: Grating sound due to inflamed pleura (pleurisy).
Note: By mastering these breath sounds and their associated conditions, you’ll be well-prepared to tackle related questions on the TMC Exam and provide accurate assessments in clinical practice.
3. Understand Abnormal Breathing Patterns
Recognizing different breathing patterns is essential for both the TMC Exam and clinical practice. Questions related to breathing patterns often appear on the exam, and knowing the distinct characteristics of each can help you quickly identify the underlying condition.
Here’s a concise guide to the key breathing patterns you need to know:
- Eupnea: Normal breathing at a regular rate and depth. This is the baseline pattern observed in healthy individuals.
- Apnea: No breathing for a period of 20 seconds or more. This is often seen in conditions such as cardiac arrest, drug overdose, or severe neurological impairment.
- Tachypnea: Fast breathing with a rate greater than 20 breaths per minute. This is typically seen in conditions like fever, anxiety, or respiratory distress.
- Bradypnea: Slow breathing with a rate of less than 12 breaths per minute. It can be caused by sedation, drug overdose, or neurological disorders.
- Kussmaul Breathing: Deep, rapid breathing pattern. This is a compensatory mechanism for metabolic acidosis and is commonly seen in diabetic ketoacidosis (DKA).
- Cheyne-Stokes Breathing: Alternating periods of deep and shallow breaths, followed by periods of apnea. This is often seen in patients with stroke, head trauma, congestive heart failure, or severe CNS injuries.
- Biot’s Breathing: Clusters of rapid breaths interspersed with periods of apnea. This is often associated with neurological diseases and damage to the medulla.
- Agonal Breathing: Gasping, labored breathing pattern, often irregular and ineffective. This is often seen in end-of-life scenarios and indicates a grave prognosis.
- Hypopnea: Shallow breathing with decreased depth and volume. It is often observed in conditions like sleep apnea or respiratory muscle weakness.
- Hyperpnea: Deep breathing with an increased volume per breath, often occurring at a normal or slightly increased rate. It is often seen in exercise, pain, or fever.
- Orthopnea: Difficulty breathing when lying flat, relieved by sitting or standing. This is a hallmark sign of congestive heart failure (CHF) or severe pulmonary disease.
For the TMC Exam, you’ll need to quickly identify the breathing pattern presented in a question and correlate it with the patient’s underlying condition.
Pay close attention to descriptors such as “deep,” “shallow,” “fast,” or “periods of apnea,” as these are key indicators that point to specific patterns.
Quick Reference Summary
- Eupnea = Normal breathing
- Apnea = No breathing
- Tachypnea = Rapid breathing (>20/min)
- Bradypnea = Slow breathing (<12/min)
- Kussmaul = Deep, fast breaths (DKA)
- Cheyne-Stokes = Cycles of deep and shallow breaths + apnea (CNS disorders)
- Biot’s = Rapid breaths + irregular apnea (neurological damage)
- Agonal = Gasping, labored breaths (end of life)
- Hypopnea = Shallow breathing
- Hyperpnea = Deep breathing
- Orthopnea = Difficulty breathing while lying flat (CHF)
Note: Understanding these patterns will help you confidently answer any related questions on the TMC Exam and enable you to better assess your patients in clinical scenarios.
4. Master Chest Percussion Notes
Chest percussion is a valuable assessment technique used to evaluate the condition of a patient’s lungs. Different percussion notes can provide clues about the presence of air, fluid, or solid tissue, helping to identify various respiratory conditions.
For the TMC Exam, it’s crucial to recognize and understand these percussion notes and what they signify.
Key Chest Percussion Notes to Remember
Normal Resonance
- Sound: Low-pitched, hollow sound.
- Indicates: Normal, air-filled lungs.
- When Heard: This is the expected sound over healthy lung fields.
Increased Resonance
- Sound: Louder, more resonant than normal.
- Indicates: Hyperinflation of the lungs.
- Common Causes: Obstructive lung diseases such as emphysema, asthma, or chronic bronchitis.
Dull Percussion Note
- Sound: Thud-like, soft sound.
- Indicates: Areas of consolidation or increased lung density.
- Common Causes: Pneumonia, pleural effusion, or a lung mass.
- Tip: Dullness indicates that something solid or liquid is replacing normal air-filled lung tissue.
Hyperresonant Percussion Note
- Sound: Loud, low-pitched, and booming.
- Indicates: Excess air trapped in the pleural space.
- Common Causes: Pneumothorax or severe COPD.
- Tip: Hyperresonance suggests the presence of free air, either within the lung or in the pleural cavity.
Flat Percussion Note
- Sound: Extremely soft, high-pitched sound, almost no resonance.
- Indicates: Areas of atelectasis or complete lung collapse.
- Exam Hack: Remember “Flat-electasis” because flat sounds are associated with atelectasis.
- Tip: Flatness indicates a complete lack of air, as in collapsed alveoli or lung tissue.
Questions on the TMC Exam will often describe a patient’s condition and provide clues using percussion findings. Knowing what each sound represents will help you accurately identify the problem and recommend the appropriate treatment.
Quick Reference Summary
- Normal Resonance = Healthy, air-filled lungs.
- Increased Resonance = Hyperinflation (Obstructive lung disease).
- Dull Note = Consolidation (Pneumonia, Pleural Effusion).
- Hyperresonant Note = Excess Air (Pneumothorax, Severe COPD).
- Flat Note = Atelectasis (Lack of air in lung tissue).
Note: By mastering these percussion notes and their clinical significance, you’ll be better prepared to handle related questions on the TMC Exam and assess patients more effectively in clinical practice.
5. Know When to Recommend a Chest X-Ray
Knowing when to recommend a chest x-ray is essential for the TMC Exam, as this skill will be tested in various patient scenarios. Chest x-rays are commonly used to confirm diagnoses, assess treatment efficacy, and ensure the correct placement of tubes and lines.
Below are key situations in which you should recommend a chest x-ray and other important thoracic imaging options to be familiar with for the exam.
Indications
- To Verify ET Tube Placement: After intubation, a chest x-ray is needed to confirm that the endotracheal tube is positioned correctly—typically 3–6 cm above the carina.
- To Check for a Foreign Body Obstruction: If a foreign body is suspected, an x-ray can help identify the location and guide removal strategies.
- To Confirm or Rule Out a Pneumothorax: A chest x-ray is crucial for visualizing free air in the pleural space, which appears as an area without lung markings.
- To Verify Chest Tube Placement: After inserting a chest tube, an x-ray ensures that the tube is positioned correctly and effectively draining air or fluid.
- To Assess a Patient with Sudden Respiratory Decline: If a patient’s condition rapidly deteriorates, an x-ray can help identify the underlying issue, such as pneumothorax, atelectasis, or new-onset consolidation.
Other Imaging Techniques to Know
- Computed Tomography (CT) Scan: A CT scan provides cross-sectional images of the body using multiple x-ray measurements taken from different angles. It is ideal for obtaining detailed images of organs and tissues, such as detecting lung masses, tumors, or pulmonary nodules. A CT scan is a preferred method for assessing complex lung conditions when more detail is required beyond a standard x-ray.
- Ventilation-Perfusion (V/Q) Scan: A V/Q scan uses radiographic tracers to evaluate the airflow (ventilation) and blood flow (perfusion) in the lungs. It is typically used to diagnose or rule out a pulmonary embolism. A mismatch between ventilation and perfusion is a hallmark sign of a pulmonary embolism on a V/Q scan.
- Positron Emission Tomography (PET) Scan: A PET scan uses radioactive tracers to measure the metabolic activity of tissues and organs. It is frequently used for the diagnosis and evaluation of lung cancer by identifying areas of increased metabolic activity. PET scans are often recommended when a lung mass is found to determine if it’s malignant or benign.
Note: Mastering these imaging modalities and their appropriate use will help you confidently answer related questions on the TMC Exam and make accurate recommendations in clinical practice.
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Final Thoughts
Mastering the patient assessment section of the TMC Exam is crucial for becoming a skilled respiratory therapist. By focusing on key assessment techniques, recognizing abnormal findings, and understanding how to prioritize care, you’ll be well-prepared for this part of the exam.
If you found these tips helpful, be sure to check out our TMC Exam Hacks video course for more expert advice, insider strategies, and insights to help you succeed. Best of luck on your journey to becoming a registered respiratory therapist (RRT).
Written by:
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
References
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- Mosby’s Respiratory Care Equipment. Cairo, JM. 11th Edition. Elsevier. 2021.
- Pilbeam’s Mechanical Ventilation. Cairo, JM. Physiological and Clinical Applications. 8th Edition. Saunders, Elsevier. 2023.
- Rau’s Respiratory Care Pharmacology. Gardenhire, DS. 11th Edition. Elsevier. 2023.
- Wilkins’ Clinical Assessment in Respiratory Care; Heuer, Al. 9th Edition. Saunders. Elsevier. 2021.
- Clinical Manifestations and Assessment of Respiratory Disease. Des Jardins, T, & Burton, GG. 9th edition. Elsevier. 2023.