Cardiopulmonary Assessment Questions

• Cardiopulmonary issues are being discussed

Coughing

• The most prevalent sign in cases of pulmonary disease
• Is caused by stimulated receptors in the pharynx, larynx, trachea, large bronchi, lung, and visceral pleura
• Consists of three phases:
  • Inspiratory: glottis opens reflexively, diaphragm, thoracic and abdominal muscles contract to increase lung volume
  • Compression: glottis closes, diaphragm relaxes, and expiratory muscles contract with high intra-thoracic pressure
  • Expiratory: glottis opens, which causes an explosive release of trapped intra-thoracic air

Coughing

• Can be characterized as acute or chronic, with chronic being longer than 3 weeks
• Common causes of chronic cough include:
  • Asthma
  • Gastroesophageal reflux disease (GERD)
  • Chronic bronchitis
  • Left heart failure
  • Lung cancer
• 25% with chronic cough have more than one cause
• Problems include fatigue, muscle strain, rib fractures, pneumothorax, syncope, arrhythmia, oesophageal rupture, and urinary incontinence
• Can be described as effective, inadequate, productive, or dry

Cough Receptors

• Cough receptors can be stimulated by a number of possible causes
  • Inflammatory causes - infection, lung abscess, drug reaction, allergy, edema, hyperemia, collagen-vascular disease, radiotherapy, pneumoconiosis, or tuberculosis
  • Mechanical causes- inhaled dusts, foreign bodies, aspiration of nasal secretions, tumor/granulomas within or around the lung, or aortic aneurysm
  • Obstructive causes - pulmonary edema, atelectasis, fibrosis, or chronic interstitial pneumonitis
  • Airway wall tension
  • Chemical causes - inhaled irritant gases, fumes, or smoke
  • Temperature causes - hot or cold air
  • Ear causes - tactile pressure in the ear canal or otitis media

Terms to Describe Coughing

• Terms used to describe coughing:
  • Recurrent (children) - allergies, asthma
  • Dry - viral infection
  • Dry progressing to productive - smoking, emphysema (late)
  • Chronic productive - bronchiectasis
  • Inspiratory stridor - (croup) epiglottitis
  • Wheezy - asthma
  • Paroxysmal (often at night) - asthma, left heart failure
  • Barking - croup

Sputum Production

• Sputum comes from the bronchial tree, pharynx, mouth, sinuses, and nose
• Phlegm, from the lungs and tracheobronchial tree, contains cellular debris, microorganisms, blood, pus, and foreign particles, and should not be confused with saliva
• Normal secretion is approximately 100 mL/day
• When describing sputum, note color, consistency, quantity, odor, and presence of blood

Sputum Analysis Table

• Possible sputum analyses:
  • Clear, colorless: normal
  • Black: smoke inhalation
  • Brownish: smoker
  • Frothy white or pink: pulmonary edema/pathognomic
  • Purulent: secretions that have infection
  • Apple-green and thick: H. influenzae
  • Red currant jelly: Klebsiella
  • Yellow or green and copious: Pseudomonas pneumonia
  • Mucoid - Thick, white, copious
  • Muco-purulent: mucoid and purulent mixed from infection and foul smelling-cystic fibrosis or lung abscesses

Hemoptysis

• Key facts about hemoptysis:
  • Characterized by expectoration of bloody sputum, derived from anywhere in the lung, mouth, or nose
  • Common reasons include bronchogenic carcinoma and chronic bronchitis
  • Acute bronchitis with severe coughing may also lead to it
  • Streaky hemoptysis causes are pulmonary infections, lung cancer, and thromboembolism
  • Massive hemoptysis causes can be lung carcinoma, tuberculosis, bronchiectasis, and trauma
  • As an emergency, it is associated with mortality as high as 75%

Types of Hemoptysis

• Evaluate the amount of blood and what it contains
• Clots suggest a serious illness
• A massive amount is 400 mL in 3 hours or more
• Giving respiratory treatments may be needed if bleeding stops and contact the senior
• Bright red from lungs, coffee-ground appearance is from stomach

Dyspnea

• Defined as unpleasant awareness of difficulty breathing
• Most distressing symptom of respiratory disease and a cardinal symptom of cardiac disease
• Frequently impairs the ability to work and could interfere with normal daily activities
• Common cause in children is asthma

Dyspnea Scales

• Causes in adults include COPD, congestive heart failure (CHF), and severe anemia
• 5-point Likert scale
  • Includes the absence of dyspnea (a score of 1)
  • Mild shortness of breath (a score of 2)
  • Moderate shortness of breath (a score of 3)
  • Severe shortness of breath (a score of 4)
  • Worst possible shortness of breath (a score of 5)
• The scale is used in pulmonary rehabilitation

Dyspnea Scale

• The Modified Medical Research Council (mMRC) dyspnea scale:
  • Grade 0: Only get breathless with strenuous exercise
  • Grade 1: short of breath when hurrying on level ground or walking up a slight hill
  • Grade 2: On level ground, I walk slower than people of my age because of breathlessness, or I have to stop for breath when walking at my own pace on the level
  • Grade 3: I stop for breath after walking about 100 yards or after a few minutes on level ground
  • Grade 4: I am too breathless to leave the house or I am breathless when dressing/undressing

Stages of Heart Failure

• NYHA (New York Heart Association) Classification helps define the stages of heart failure
• Class I: No symptoms or limits to ordinary physical activity, like shortness of breath when walking or climbing stairs
• Class II: Mild symptoms like mild shortness of breath/angina with mild limits to ordinary activity
• Class III: Marked limits to activity due to symptoms even during less-than-ordinary activity, like walking short distances and comfortable only at rest
• Class IV: Severe limits so experience symptoms even while at rest, so they're mostly bedbound
• No NYHA - Class listed or unable to determine

Six Minute Walk Test (6MWT)

• Aids in the determination of COPD in the patient
• The test is on a straight, 30-meter track
• Suggested equipment includes:
  • Recording form
  • Borg scale
  • Pulse oximeter with sensor
  • Stopwatch or timer
  • Chairs dependent on the patient condition and risk
  • Sphygmomanometer and a stethoscope
  • Trundle wheel
  • Clipboard for recording
  • Portable oxygen (if indicated)

BORG SCALE

• For dyspnea, the Borg scale asks patients to rate the difficulty of their breathing
• It begins and goes up to the point where breathing is severely impacted
• It starts at 0 where breathing causes no difficulty, with the values progressing to number 10, which is maximal difficulty

Dyspnea Types

• Paroxysmal nocturnal dyspnoea (PND)
  • Is a sudden onset of dyspnea when you're flat
  • Pathognomonic of CHF or, congestive heart failure
  • Usually occurs in first 1-2 hours down in paroxysm/sudden attack
  • May include frothy white sputum, need several pillows
  • Related to Left heart failure
• Orthopnea:
  • Inability to breathe while lying down, so patient uses more pillows

Dyspnea Terms

• Other dyspnea terms:
  • Treopnoea - can only lie on one side
  • Pleural effusion
  • Platypnea - dyspnea in an upright position
  • Orthodeoxia - decreased oxygen saturation
  • Relieved by recumbent position
  • Heart Disease - heart problem

Dyspnea Terms

• These exist in addition to hypo and hyperventilation
  • Hyperventilation - increased ventilation and either an increasing rate or depth of breath
    • Leans to a decrease in carbon dioxide in a PaCO2 of the blood
  • Hypoventilation - decrease in ventilation
    • Decrease with rate or depth of breathing
    • Leads to an increase in carbon dioxide
    • Both assessed using blood gas

Dyspnea and Medical Conditions

• Divided between Acute and Chronic - Acute - Childhood problems like asthma, chest trauma and pneumonia - Chronic - Dyspnea that progresses from an exertion to rest progressing Asthma, Left heart failure and cysts and fibrosis
• Inspiratory and Expiatory Dyspenea - occur in both situations

Important notes on dyspnea, associated symptoms and types of patients.

• This slide details an overview of a number of conditions and symptoms, including:
  • Asthma - includes cough
  • Pneumothorax - includes sharp pneura and cough
  • Pleuritic chest pain - includes hemoptysis
  • Hyperventulation
• It shows what is important by type
• These conditions can occur for a number of reasons, from allergies, family history and lung condition as side affects

Chest Pain

• Indicates involvement of chest wall, parietal pleura - Chest wall pain localized and constant
• Pleuritic pain is sharp with abruptly inspiration
• Possible origin from chest muscles, cartilages increasing pain with limb or chest pressure that stretches
• May also come from arm, jaw or back
• Can originate in heart, great vessels, and esophagus
• Patients positioning, breathing, and descriptive terms show pain
• It could be said, patient reclines on the painful side, helping alleviate it

Conditions

• Symptoms of chest pain
• Localization/ characristics Causes / etiology are conditions like :
  • Chest wall/ myalgia, localized and increased moving. Due to trauma and exercise can lead to ecchymosis
  • Pleuretic chest pain increased sharpness is caused by infection and inflammation can result in coughing and high temperatures
  • cardiac pain, substernal or central, increase pressure, CAD IHD and affects thearterial area, and can lead to shortness of breath

Syncope or Fainting

• Temporary loss of consciousness caused by reduced blood flow to the brain
• Vasovagal syncope - dizziness and fainting. Most usual with prolonged time
• Other types include orthostatic , hypotension, and upon assuming.

Pulmonary Causes

• Pulmonary events cause syncope:
  • Pulmonary embolism
  • Pulmonary hypertension
  • Coughing spells (Tussive Syncope
  • Valsalva maneuver
  • Tussive Syncope - Middle Aged

Dependent Edema

• A soft tissue swelling in pitting form (or where the pit remains)
• Can be localized or generalized
• Associated with kidneys, heart and lungs
• Unilateral is venous

Dependent Edema

• Progression : feet and ankles abdominal
• Affect organs - hepatomegaly - jugular
• Rapid pitting scale - + severe

Jugular Vein

• Reflection of blood column
• Supine Full JVP
• 45 deg, Normal 3-5cm Clavicle
• High venous pressure - patient sits upright
• Measurement is above sternum

Fever

• Euthermia is a fever range (36 - 37) degrees
• Constant fever or in conjunction means problems
• Fever manifestation - infection common
• Always search for an origin

Altered Mental State

• Pulmonary function of the brain is due to Cerebral
• Higher C02 and morning headaches due to lack of oxygen
• Change in emotion with Progressive function

Upper Airway Function

• Musical sounds with bronchiles are associated with Odemas or inflammation

• Snoring

• Severe airway obstruction

• Common side effect from obesity

Questions covering patient classification using NYHA, six minute walk test, orthopnea and paroxysmal nocturnal dyspnea, and the cough reflex mechanism. This also includes causes for persistent and chronic coughing.