Patient Assessment: RCP 100

• Bedside assessment involves evaluating critical life functions, monitoring, reviewing records, physical examination, and patient interviews.

4 Critical Life Functions

• Ventilation involves moving air in and out of the lungs, measure RR, chest movement, breath sounds, and PaCO2
• Oxygenation involves getting oxygen into the blood, measure HR, color, sensorium, and PaO2
• Circulation involves moving the blood through the body, measure pulse, HR and strength, and cardiac output.
• Perfusion involves getting blood and oxygen into the tissues, measure blood pressure, sensorium, temp, urine output, and hemodynamics.

Monitoring Life Functions

• Almost every part of the assessment relates to one of the items listed.
• Treat or correct any signs of patient problems immediately.
• If a patient is diaphoretic during breathing treatment, stop, assess, and call for rapid response if needed.
• A rapid response is needed, if a patient who is desating, doesn't start treatment until stabilized, start or increase oxygen therapy
• Call a code blue if any of the four critical life functions are absent.
• Ventilation: establish an open airway and breathe
• Oxygenation: increase FIO2
• Circulation: chest compressions, drugs, etc.
• Perfusion: increase blood pressure

Reviewing Patient Records

• Admission notes include admitting diagnosis, history of present illness, chief complaint, and past medical history
• Signs are objective information (color, pulse, edema, blood pressure)
• Symptoms are subjective information told by the patient (dyspnea, pain, nausea, muscle weakness)
• Occupation or employment history information is important
• Check for allergies or allergic reactions, especially medications and dyes
• Note prior surgery, illness, and injury

Patient Records Continued

• Check vital signs (respirations, pulse, BP, temp)
• Perform a physical exam of the chest (inspection, A/P diameter, palpation, percussion, auscultation)
• Pack years are calculated by multiplying the number of packs per day by the number of years smoked; e.g., smoked 2 packs per day times 20 years = 40 pack year history
• Advance Directives and code status are important details

Patient Evaluation

• Respiratory orders include the type of treatment, frequency, & meds
• Patient progress notes include date, time (24-hour clock), reactions, etc.
• Nursing notes check patient status
• Admission notes - records pertinent patient data
• Physician notes indicate corresponding respiratory orders if change in condition
• Lab reports include ABG, CBC, BUN, Creatinine, Troponins, PFT, x-rays, CT, MRI, etc.

General Appearance

• Observing general appearance is the first step in a physical exam
• Gain a picture of the individual as a whole
• Documentation should reflect that picture
• Inspection should begin upon first encountering the patient
• Note gender, ethnicity, age, height, weight, and general state of health
• Facial expression and general appearance provide clues as to emotional and nutritional status

General Appearance Questions

• Is the patient awake, alert, and responsive?
• Is the patient relaxed and resting quietly?
• Is the patient anxious, restless, or disoriented and/or confused?
• Lying down, sitting up, or other position?
• Are there any signs of respiratory distress?
• What ancillary equipment/supplies are in use i.e. oxygen equipment, monitoring equipment, or intravenous lines?
• What is the patient's general state of health?
• Note the patient's overall condition, level of consciousness, respiratory rate and pattern, and signs of respiratory distress
• Note the patient's color and if the patient is sweating excessively
• Note patients' SpO2, along with any supplemental O2
• Note the cardiac rate and rhythm and observe for gross arrhythmias if cardiac monitoring equipment is in use
• General inspection should include the head and face, neck, hands and fingernails, and skin of the arms and extremities

Emaciated Patients

• Emaciated patients are very thin and "wasting away."
• These patients have poor nutritional status and are very weak
• Weak patients may develop atelectasis, pneumonia, or both because they breathe shallow
• Cachexia is another term for emaciated

Skin

• Inspecting the patient's skin can detect changes in color, edema, or diaphoresis.
• Skin color varies with pigmentation; nail beds and gums should be pink.
• A pale appearance with cold, clammy skin indicates shock or hypotension.
• Angioedema is swelling in the face, tongue, larynx, hands, or feet.
• Angioedema is caused by allergic reactions, drug reactions, or food allergies.

Diaphoresis

• Excessive sweating can be a sign of acute respiratory distress or cardiac disease (myocardial infarction, congestive heart failure).
• Sweating can also be caused by fever, infection, certain drugs/medications, anxiety, stress, pain, low blood sugar, or withdrawal from alcohol or narcotic drugs.

Assessing Skin Color

• Look at the patient's color
• An abnormal decrease in color (ashen, pallor) can be due to anemia or acute blood loss.
• Jaundice indicates liver failure
• Erythema is redness of the skin and could be capillary congestion, inflammation, or infection.
• Ecchymosis is superficial bleeding under the skin and is common in elderly patients.

Assessing Skin Color - Cyanosis

• Cyanosis is a bluish discoloration of the skin, nail beds, and mucus membranes caused by an elevated level of desaturated hemoglobin (Hb) in the arterial blood.
• Cyanosis is observed in the lips, gingiva (gums), and nail beds of the fingers and toes.
• Central cyanosis refers to cyanosis of the oral mucosa or trunk.
• Peripheral cyanosis is observed in the hands, fingertips, and nail beds of the hands and feet.
• Developing cyanosis requires the level of unsaturated Hb to exceed 4 to 5 g/dL
• At normal Hb (15 g/dL), cyanosis occurs when oxygen saturation falls to < 73% (4 to 5 g/dL of desaturated Hb).
• Differentiate whether cyanosis is caused by a cardiac or respiratory problem
• Respiratory causes of cyanosis include hypoventilation and impaired gas exchange in the lung
• Cardiac causes of cyanosis include congenital cardiovascular anomalies where deoxygenated blood is shunted from the right to left side of the heart and then pumped to the peripheral tissues.

Other Alterations in Skin Color

• A pale, cold, clammy appearance is just as ominous as cyanosis
• A skin rash combined with mucosal edema, nasal polyps, and aspirin intolerance are common in allergic asthma and is known as triad asthma.
• Carbon monoxide poisoning may produce a bright cherry red skin color.

Patient Interview - Level of Consciousness

• Determine LOC:
  • Alert and responsive reflects normal
  • Lethargic, somnolent, and sleepy may indicate OD or sleep apnea
  • Stuporous and confused may indicate drug OD or intoxication
  • Semicomatose responds only to painful stimuli
  • Obtunded is a drowsy state that may have decreased cough or gag (Risk)
  • Coma is when there is no response to painful stimuli.

Examination of Thorax

• Barrel chest is seen in emphysema and indicates poor lung recoil or increased compliance
• Retractions, skin being sucked inward during inspiration
• Tracheal tugging

Further Examination of Thorax

• Pectus carinatum is an abnormal protrusion of the sternum
• Pectus excavatum is an abnormal depression of the sternum
• Kyphoscoliosis is an abnormal curvature of the spine that often causes severe restrictive lung disease

Patient Interview Details

• Check orientation to time, place, and person
• Well-oriented: cooperative, knows people
• Disoriented is confused and delirious
• To assess a patient's ability to cooperate, have them perform simple tasks or repeat instructions (name & DOB)
• Inability to cooperate may be due to: language difficulties, influence of medications, hearing loss, fear, apprehension, depression etc

Patient Interview - Emotional State

• Assess anxiety or nervousness which may indicate asthma, respiratory distress, or hypoxemia
• Depressed may present as quiet
• Anger, combativeness, or irritability may indicate electrolyte imbalance
• Euphoria is the result of drug overdose, as with morphine
• Panic reflects hypoxemia, tension pneumothorax, or status asthmaticus

Interviewing Technique

• Introduce yourself in social space (~4-12 feet)
• Interview in personal space (~2-4 feet)
• Use appropriate eye contact
• Assume a physical position at the same level as the patient
• Avoid leading questions; use neutral questions. Example: "How is your breathing now?" is more netural when compared to "Is your breathing better now?"
• Open-ended questions often encourage patients to describe events and priorities as they seem them
• Closed questions focus on specific information, such as "When did your cough start?"
• Direct questions can be open-ended or closed, but avoid responding with one word since this can be intimidating
• Neutral questions are preferred for all interactions

Cardiopulmonary Symptoms

• Dyspnea is the sensation of breathing discomfort (subjective feeling); the most important symptom respiratory therapists assess & treat
• Orthopnea: difficulty breathing except in the upright position, indicates a heart problem or CHF
• Platypnea: difficulty breathing in an upright positionDyspnea is a subjective experience
• Subjective experience is important, cannot be inferred from observing breathing patterns

Describing Dyspnea

• Assess describing it with patients own words
• How patient describes breathing can help determine cause, such as atelectasis, asthma, restriction or obstruction
• Patients with CHF feel SOB when laying down due to fluid shifting from lower extremities to lungs, reducing pulmonary compliance

Language of Dyspnea

• Ask patient about dyspnea quality & characteristics to determine cause
• Asthma patients frequently complain of chest tightness
• Patients with CHF may complain of feeling suffocated

Psychogenic Dyspnea: Panic Disorders & Hyperventilation

• Patients have normal cardiopulmonary function but intense dyspnea & suffocation
• May coincide with symptoms like chest pain, anxiety, palpitation & paresthesia (tingling & numbness in extremities that occurs with respiratory alkalosis)
• Anxiety often accompanied by breathlessness & hyperventilation
• Do not assume all SOB is caused by anxiety, it could be hypoxia, pain, or temp
• Assess the cough!

Cardiopulmonary Cough

• Cough occurs when cough receptors in airways are stimulated by inflammation, mucus, foreign material, or noxious gases
• Cough receptors are located primarily in the larynx, trachea, and larger bronchi
• Weak cough is often due to high Raw, poor lung recoil, weak muscles or pain
• Nonproductive cough is typical for restrictive lung diseases, CHF, pulmonary fibrosis
• Loose productive cough is associated with inflammatory obstructive diseases like bronchitis and asthma
• Causes of chronic cough: asthma, postnasal drip, chronic bronchitis, and GERD
• Certain ACE Inhibitor cardiac meds can cause cough

Cardiopulmonary - Sputum

• Mucus from tracheobronchial tree not contaminated by oral secretion is called "phlegm"
• Mucus from lower airways but is expectorated through mouth is called "sputum"
• Sputum having pus cells is said to be "purulent"
• Foul smelling sputum is "fetid"
• Recent changes in sputum color, viscosity, or quantity may indicate infection and must be communicated to the Physician.
• Mucus is gradually moved into the hypopharynx by the mucociliary escalator, where it is swallowed or expectorated
• Hemoptysis: coughing up blood or bloody sputum from the lungs
• Blood-streaked sputum is common patients with chronic lung disease
• Frank hemoptysis is primarily blood in the expectorant
• Hemoptysis is characterized as massive or non-massive
  • Massive: > 300 ml of blood expectorated over 24 hours. Common causes: bronchiectasis, lung abscess, & acute or old tuberculosis. Distinguished from hematemesis (vomiting blood from the gastrointestinal tract)
  • Non-massive: Common causes: infection of the airway, tuberculosis, trauma & pulmonary embolism

Sputum Analysis

• Amount of sputum: small, moderate, large, copious
• Consistency: thin, thick, tenacious
• Color:
  • Clear is normal
  • Mucoid (white/grey) may indicate chronic bronchitis
  • Yellow indicates presence of WBCs and may indicate bacterial infection
  • Green stagnant sputum may indicate gram negative bacteria
• (bronchiectasis, pseudomonas)
  • Brown/dark is old blood
  • Bright red hemoptysis indicates bleeding tumor or TB
  • Pink frothy indicates pulmonary edema
• Sputum culture identifies bacteria present
• Sensitivity identifies what antibiotics will kill the bacteria
• Gram stain identifies whether it is gram positive or gram negative
• Acid fast stain identifies mycobacterium TB

Pain

• Pain may be:
• Somatic: arising from skin, muscles, soft tissue, bones, ligaments, or tendons
• Visceral: arising from the viscera in body cavities due to ischemia, inflammation, or injury
• Neuropathic: due to a nerve injury
• Note different varieties, and scales used
• Patients may experience generalized or localized pain due to injury/disease
• Chest pain is common in cardiopulmonary problems
• Abdominal pain is caused by gastric/intestinal issues
• Acute intense pain and hemodynamic instability are medical emergencies
• Causes of pain are tissue damage due to specific disease
• ICU pain management is often inadequate potentially causing stress
• assess pain reports, using common pain scales

Chest Pain

• Pleuritic chest pain is located laterally or posteriorly; sharp, stabbing, increases with deep breathing, caused by pulmonary embolism or pneumonia, and associated diseases causing pleural lining inflammation.
• Non-pleuritic chest pain is located at the center of the anterior chest and may radiate to the shoulder/arm. It's often caused by coronary artery disease/angina or esophageal/gallbladder diseases
• Fever (hyperthermia), also known as febrile, is an Elevation of body temperature due to disease, sympathetic storming, simple viral infection of upper airway or with serious bacterial pneumonia, tuberculosis, & some cancers
• This causes an increased metabolic rate, oxygen consumption & carbon dioxide production
• Hypothermia reduces O2 and CO2 and HR (heart rate), use "Code Cool” on MI patients

Patient Evaluation - Intake & Output

• Normal Urine Output: 40 mL/hr
• Approximately 1 Liter/day
• Sensible water loss urine/vomiting
• Insensible water loss lungs/skin
• If intake exceeds output:
  • Weight Gain
  • Electrolyte Imbalance
  • Decreased lung compliance

Pedal Edema

• Pedal edema is a common with heart failure and causes an increase in hydro static pressure in the blood vessels of lower extremities
• This causes fluid to leak into the interstitial space
• Which causes pedal edema
• Rated at +1, +2, +3, +4 or weeping , the higher indicates severe swelling or tissue damage where fluid is leaking out
• Ankle swelling is most often heart failure
• Pulse is evaluated for rate, rhythm, and strength

Measuring Pulse

• Evaluate pulse for its rate, rhythm, and strength
• Normal range: 60-100 bpm
• Tachycardia is when is greater than 100, and assess for hypoxemia, anxiety and the related
• Bradycardia is less than 60, assess for heart failure.
• Some athletes and quadriplegic patients have a lower pulse which is normal for them Pulmonary disease can affect HR.

Physical Exam - Respiratory Distress

• Pulsus paradoxus (paradoxical pulse) is a decrease in BP >10 mmHg during inspiration, measure using blood pressure cuff
• Common in acute COPD, asthma, cardiac tamponade, restrictive pericarditis
• During respiratory distress, vigorous inspiratory efforts decrease stroke volume because it is impeding the strength of the left ventricular contraction
• Normal respiratory rate 12-20, measured in breaths
• Apnea 0, respiratory arrest
• Tachypnea >20, hypoxemia, fever related causes
• Bradypnea <12, narcotic related causes

Assessing Breathing Patterns

• Hyperpnea: increased RR and depth of breathing but regular rhythm, causes: Metabolic Acidosis
• Cheyne-Stokes: gradually increasing then decreasing rate and depth in a cycle lasting from 30-180 seconds with period of apnea lasting up to 60 seconds
• Biot's: Increased RR and depth with irregular periods of apnea. Each breath has the same depth
• Kussmauls: Increased rate over 20, increased depth, irregular rhythm, breathing sounds labored
• Causes: DKA, metabolic acidosis renal failure
• Apneustic: prolonged gasping inspiratory followed by very short expiration, can have neurological related causes

Assessing Blood Pressure

• BP is impacted/created by the heart, blood, and vessels
• Three factors affect/control BP Heart Heart is a pump that creates BP and changes with heart Increase HR/strength increase BP Decrease H/strength decrease BP Blood Amount impacts BP Excessive fluids – raise Loss of fluids – lower Vessels Constriction increases and dilation lowers. Measuring vessel constriction and related issues with a sphygmomanometer Changes occur Shock is when there inadequate O2 nutrients, cardiogenic shock Orthostatic hypotension

Physical Exam - Neck

• Check jugular neck veins
• The trachea should be midline and doesn't naturally distend jugular veins
• Trachea goes left or right tumors
• Distension JVD occurs with CHF or and related issue (Cor-pulmonale)

Chest Exam - Evaluating Fremitus

• Tactile vocal fremitus - occurs with atelectasis.
• Tactile fremitus in reduced with emphysema, pneumothorax, and pleural effusion. Rhonchial fremitus secretions .

Chest Exam - Percussion

• Resonant is normal, air filled lung
• Is Flat: heard over sternum, muscles, or atelectasis
• Can be Dull which occurs with fluid filled organs.
• Tympanic- heard over air filled area .
• Hyper resonant occurs due to the lung, with Emphysema and related distention

Chest Exam - Breath Sounds

• Normal breath sounds = Vesicular
• Two sided = Bilateral
• Bronchial = normal over the trachea.
• Compare to other side, start from lower bases of the lungs.

Auscultation

• Bronchial breath sounds: When should not occur.
• Diminished breath sounds.
• Wheezes may indicate airway obstructions.
• Stridor: upper mono constricting
• In emergencies marked stridor may be so severe it need intubated
• Supraglottic swelling could indicate (epiglottitis)
• Subglottic swelling (Croup)

Breath Sounds - Secretions

• Coarse with coarse crackles (aka rhonchi)
• Large secretins, need suction
• Air coming thought secretions
• Clear through suction or cough.

Crackles Explained

Fine crackles and related components Sudden with small airways opening. Is associated congestive heart failure. Treat: heart conditions.

Digital Clubbing

• Digital clubbing may be seen in large variety of chronic -conditions: congenital heart disease, chronic bronchitis, various cancers, & interstitial lung diseases