cardiorespiratory assessment cresp wk 10_ tut 2_10_111
TRANSCRIPT
CResp Wk 10_ Tut 2_10_11 1
Overview of respiratory and cardiovascular assessment to give you a framework on which to base your assessment process when out on clinical placement for the self ventilating adult patient
Handout on StudyNet Please read around in the textbooks
CResp Wk 10_ Tut 2_10_11 2
From lecture: Why do we assess patients?
◦ To identify physiotherapy problems for management
◦ To ascertain the patient’s perceptions of their problems
◦ To identify potential indications for treatment techniques/management strategies
◦ To identify potential contra-indications for treatment techniques/management strategies
CResp Wk 10_ Tut 2_10_11 3
From lecture: When do we assess patients?
◦ First contact◦ Ongoing throughout treatment◦ Before and after every patient contact◦ Maybe use more formal outcome measures at
certain times during management ◦ Before discharge
CResp Wk 10_ Tut 2_10_11 4
Subjectively◦ Everything the patient/other staff tell us about
the patient’s condition Objectively
◦ Everything we see/identify from charts/measure
(remember: points from other modules about writing up etc)
CResp Wk 10_ Tut 2_10_11 5
From patient or medical notes◦ HPC
(PC)
◦ PMH◦ SH
Including smoking, hobbies, accommodation
◦ FH◦ Occupational history◦ DH
Including allergies
CResp Wk 10_ Tut 2_10_11 6
Medical test results◦ Sputum MC+S◦ CXR
current and any previous◦ Pulmonary/Lung Function Tests
Peak Expiratory Flow Rate (litres per minute) Spirogram - expiration Flow volume loops –expiration into inspiration
◦ ABGs current and any previous
◦ Blood test results Hb (14-18 g/100ml Men, 11.5-15.5g/100ml Women) ? Raised white cell count (N= 4-11x109 per litre) Cardiac enzymes (Creatine Kinease, Troponin T)
Any reported ECG abnormalities
CResp Wk 10_ Tut 2_10_11 7
The graph produced from a max. forced expiration following a full inspiration is called a forced expiratory spirogram.
Spirometer Measures: -forced expiratory vol. in 1 second (FEV1)-forced vital capacity (FVC)-peak expiratory flow rate-Normal ratio FEV1/FVC around 80% (75-85%)
Obstructive pattern: ◦ ↓ FEV1, ↔ FVC (ratio < 75%)
Restrictive pattern: ◦ ↓ FEV1, ↓ FVC (ratio usually above 90%)
Calculate your values against normative data at http://www.patient.co.uk/showdoc/40002357/
Normal values based on age, height and gender.
CResp Wk 10_ Tut 2_10_11 8
Current drugs◦ ?? Oxygen: route/duration and concentration◦ Bronchodilators: timings of doses to fit in with
your treatment◦ Analgesia: timing to fit in with your treatment◦ Antibiotics◦ Inhaled steroids◦ Nebulisers
CResp Wk 10_ Tut 2_10_11 9
Shortness of breath (SOB) - When?◦ On Exertion (SOBOE)◦ At Rest (SOBAR), or at Night
Sleep with how many pillows? Orthopnoea
Unable to lie flat without becoming dyspnoeic Supposedly classic of pulmonary oedema but present in
many respiratory diseases
Paroxysmal nocturnal dyspnoea (PND) Sudden waking at night because of breathlessness. Supposedly classic of pulmonary oedema but present in
many respiratory diseases, especially morning dips of asthma
? Wake up coughing ? snoring
CResp Wk 10_ Tut 2_10_11 10
Cough◦ When◦ Exacerbating factors◦ Type; dry or productive, +/- painful, ?pattern◦ Productive of phlegm/sputum?
Colour: consistency, smell, taste Volume: teaspoon, egg cup, yoghurt
pot Ease of expectoration
CResp Wk 10_ Tut 2_10_11 11
Chest Pain:◦ Location◦ Type
◦ Aggravating factors How long does it last when aggravated?
◦ Easing/relieving factors?
◦ Aiming to ascertain Is it pleuritic in nature Localised/sharp, stabbing- worse on Inspiration Is it cardiac in nature? (dull, central, gripping +/- radiates
to jaw & arm) Is pain relief adequate? Is there a musculoskeletal component?
CResp Wk 10_ Tut 2_10_11 12
Normal = mucoid◦ White/clear
Smokers◦ White with variable amounts of grey/black flecks/brownish
Infected = purulent◦ Yellow – some form of infection◦ Green (apple green classic of haemophilus influenza)◦ Dark green/brown - pseudomonas◦ Rusty brown – classic of pneumoccocal pneumonia◦ Red currant jelly - klebsiella
Consistency◦ Very thick ? Need humidification/increase in fluid intake◦ Very loose and frothy
Maybe pulmonary oedema especially if white tinged with pink◦ Bronchial casts – asthma, occasionally bronchiectasis
CResp Wk 10_ Tut 2_10_11 13
Blood stained = haemoptysis◦ Occasional flecks during acute infection – monitor◦ Excess over longer time period indicative of cancer◦ Other causes:
Pulmonary embolism/infarct TB Ruptured blood vessel in bronchial mucosa (reasonably common
with CF/bronchiectasis) Old/new (dark/bright red)/frank haemoptysis Smell! Taste (to the patient!) Strength of cough
◦ ? Effective (esp. relevant post-op i.e pain inhibition)◦ ? Vocal cord paralysis/glottis closure
CResp Wk 10_ Tut 2_10_11 14
Exercise tolerance◦ How far without getting SOB◦ ? Hills/inclines◦ ? Stairs◦ How long do you need to rest for?◦ Anything they can’t do because of their
breathing
Depending on the circumstances◦ What the patient would like to be able to
achieve as a result of physiotherapy intervention (can give good info re. goals/motivating factors)
CResp Wk 10_ Tut 2_10_11 15
Using your handouts from StudyNet re Assessment when watching the video
◦Start to think about the order of questioning
◦The importance of listening to the answers
◦What is the usefulness of the answers – what do they mean?
CResp Wk 10_ Tut 2_10_11 16
Covert observation of patient: ◦ Appearance, Posture, Alertness, ◦ Respiratory rate/pattern (over 1min), Speech
Observation of thorax:◦ Tracheal position (mid line or shifted?)◦ Chest shape◦ Thoracic expansion
Degree Where – upper/lower/ is expansion bilateral and equal
◦ Use of accessory muscles/fixing upper limbs◦ General ease of ventilation/WOB
? Using pursed lip breathing I:E ratio, ? Prolonged expiratory phase
◦ Audible wheeze/harshness of respiration/stridor
CResp Wk 10_ Tut 2_10_11 17
Observation of fingers/hands and toes/feet◦ Cyanosis
Peripheral +/- Central
◦ Clubbing Respiratory disease (chronic) Lung cancer Liver disease Congenital
◦ CO2 flap
Observation of ankles/feet◦ Oedema◦ Perfusion
Observation of sputum
CResp Wk 10_ Tut 2_10_11 18
CResp Wk 10_ Tut 2_10_11 19
Auscultation◦ Presence of breath sounds
Decreased/absent/bronchial◦ Presence of added sounds
Crackles/wheeze Inspiratory/expiratory Pleural rub
Vocal resonance & whispering pectoriloquy ◦ Increased/decreased/normal
Percussion note?◦ Resonant/hyper-resonant/dull
CXR ◦ You assess as well as reading any reports if
available, +/- compare to previous films SpO2
CResp Wk 10_ Tut 2_10_11 20
Temperature- ◦ Core
Usually measure in the ear (rectally in ITU) Axilla about 0.5-1 0C less than core
◦ > 37.5 0C core temperature indicative of infection
◦ Peripheral About 2 0C less than core Any more indicates CVS problems in unwell patient
HR BP Peripheral oedema
◦ Indicates right sided heart failure Jugular Venous Pressure
◦ Indicates right sided heart failure◦ Normal JVP < 3-4 cm above sternal angle with the patient sitting
up 45 degrees
CResp Wk 10_ Tut 2_10_11 21
CResp Wk 10_ Tut 2_10_11 22
Exercise tests give an indication of progress Borg scale
◦ Perceived Exertion 6-20. 12-13 corresponds to 60% of VO2 max. 15 corresponds to 75% of VO2 max
◦ Be consistent MRC Dyspnoea Scale – for breathlessness Visual Analogue Scale (VAS)
◦ for breathlessness (specify which is used 0-10 or 0-5) 6MWT and modified shuttle walk test Will do in Semester B – maybe mentioned in
cardiac rehabilitation next week.
CResp Wk 10_ Tut 2_10_11 23
Visual Analogue Scale
No breathlessness Greatest Breathlessness
1 10
24CResp Wk 10_ Tut 2_10_11
Intubated and ventilated patient Paediatrics and neonates
Always remembering clinical features of hypoxaemia and hypercapnia
CResp Wk 10_ Tut 2_10_11 25
Cyanosis Tachypnoea Tachycardia → arrhythmias/ bradycardia Peripheral vasoconstriction Respiratory muscle weakness Restlessness → confusion → coma
CResp Wk 10_ Tut 2_10_11 26
Flapping tremor of hands Tachypnoea Tachycardia → bradycardia Peripheral vasodilatation leading to warm
hands and headache Respiratory muscle weakness Drowsiness → hallucinations → coma Sweating
CResp Wk 10_ Tut 2_10_11 27
You should be able to: ◦Identify the patient’s physiotherapy
problem list ◦Write a treatment plan related to the
problem list◦Identify short and long term goals◦N.B. the degree of the patient’s contribution will vary
CResp Wk 10_ Tut 2_10_11 28
Physiotherapy problem◦ Difficulty expectorating retained pulmonary secretions
Treatment plan (would need more details)◦ Teach the patient ACBT◦ Positioning to facilitate drainage of secretions◦ Added humidification◦ (Manual techniques)
Goals◦ Short term – to increase the patient’s ability to
expectorate pulmonary secretions during physiotherapy treatment
◦ Long term - to enable the patient to be independent in the management of their pulmonary secretions in a month
CResp Wk 10_ Tut 2_10_11 29
Should be S.M.A.R.T ◦ Simple◦ Measurable◦ Achievable◦ Realistic◦ Time scaled
CResp Wk 10_ Tut 2_10_11 30
A framework for all respiratory assessments (always includes CVS)◦ Detail will vary according to patient group
Practical this week◦ Some cardiovascular and respiratory tools of
assessment in practice
CResp Wk 10_ Tut 2_10_11 31
identify the importance of the physiotherapist assessing a patient at the beginning during and at the end of every treatment
identify the differences and links between the subjective and objective assessment
describe the various components of a cardio respiratory assessment
discuss the implications of the results of the assessment on the composition of a physiotherapy problem list
discuss the implications of the results of the assessment on the composition of a physiotherapy treatment plan
relate the importance of the cardiovascular system assessment to the assessment of the respiratory system
identify the components of a cardiovascular assessment begin to describe the implications of the results of a
cardiovascular assessment
CResp Wk 10_ Tut 2_10_11 32
Bourke, S. J. (2003). Lecture notes on respiratory medicine. (6th ed.). Padstow UK: Blackwell Publishing.
Harden, B. (Ed). (2004). Emergency physiotherapy. Edinburgh: Churchill Livingstone.
Hough, A. (2001). Physiotherapy in respiratory care. (3rd ed.). Cheltenham: Nelson Thornes.
Pryor, J. A. & Prasad, S. A. (Eds). (2008). Physiotherapy for respiratory and cardiac problems - adults and
paediatrics. (4th ed.). Edinburgh: Churchill Livingstone Wilkins, R. L., Sheldon R. L. & Krider, S. J. (2005). Clinical
assessment in respiratory care. (5th ed.). Missouri: Elsevier Mosby.
CResp Wk 10_ Tut 2_10_1133