RCP 100 Ch 5 Patient Assessment

• Bedside assessment includes assessing patient's 4 critical life functions

Critical Life Functions

• Ventilation involves moving air in and out of the lungs
• Ventilation assessments include respiratory rate, chest movement, breath sounds, and PaCO2 levels
• Oxygenation involves getting oxygen into the blood
• Oxygenation signs include heart rate, color, sensorium, and PaO2 levels
• Circulation involves moving blood through the body
• Circulation is assessed via pulse, heart rate and strength, and cardiac output
• Perfusion involves getting blood and oxygen into the tissues
• Blood pressure, sensorium, temperature, urine output, and hemodynamics are assessed for perfusion quality

Monitoring Life Functions

• Nearly every part of an assessment relates to the listed life functions
• Signs of problems must be treated and corrected immediately
• If a patient becomes diaphoretic during a breathing treatment, discontinue treatment to assess, and call for rapid response if needed
• For a desating patient, stabilize the patient with oxygen therapy before starting treatment, and call a rapid response if needed
• A code blue should be called if any of the four critical life functions are absent
• The first priority is ventilation by establishing an open airway and breathing
• For oxygenation, increase FIO2
• For circulation, provide chest compressions, drugs, etc
• For perfusion, increase blood pressure

Reviewing Patient Records

• Admission notes contain admitting diagnosis, history of illness, chief complaint, and past medical history
• Signs are objective and can be seen or measured, such as color, pulse, edema, and blood pressure
• Symptoms are subjective information the patient must describe, like dyspnea, pain, nausea or muscle weakness
• Occupation or employment history, allergies, past surgeries, illnesses and injuries are important for review

Reviewing Patient Records (cont.)

• Vital signs to check include respirations, pulse, blood pressure, and temperature
• Physical chest exam includes inspection, A/P diameter, palpation, percussion, and auscultation
• Smoking history is calculated as pack years, which is the packs smoked per day times the years smoked
• Advance directives and code status should be noted.

Patient Evaluation Notes

• Respiratory orders include the type of treatment, frequency, and medications
• Patient progress notes contain respiratory records date, time (24-hour clock), reactions, etc
• It is important to check patient status with nursing notes
• Admission notes record pertinent patient data, while physician notes contain information for condition changes, and corresponding respiratory orders
• Lab reports for evaluation include ABG, CBC, BUN, Creatinine, Troponins, PFT, x-rays, CT, MRI, etc

General Appearance

• Observing the general appearance is the first step in a physical exam, to gain an impression of the whole individual
• Documentation should reflect this impression
• Inspection begins upon first encounter and continues throughout the assessment
• Factors to note include gender, ethnicity, age, height, weight, and general state of health
• Facial expressions can provide clues to emotional state
• General appearance can also provide clues as to nutritional status

General Appearance Considerations

• Key questions to ask yourself when assessing general appearance
• Is the patient awake, alert, and responsive?
• Is the patient relaxed and resting quietly?
• Is the patient anxious, restless, or disoriented/confused?
• What is the patient's position (lying down, sitting up, other)?
• Are there any signs of respiratory distress?
• What ancillary equipment/supplies are in use (O2, monitoring, IVs)?
• What is the patient's general state of health?
• Additional factors to note: overall condition, level of consciousness, respiratory rate and pattern, signs of distress, and patient color
• Note SpO2 and any supplemental O2
• If using cardiac monitoring equipment, note the cardiac rate, rhythm, and any arrhythmias
• Perform general inspection of the head, face, neck, hands, fingernails, skin of the arms and extremities

Emaciated Appearance

• Emaciated patients look very thin and "wasting away"
• They usually present with a poor nutritional status and are very weak
• Weakness can lead to shallow breathing, increasing risks of atelectasis and pneumonia
• Another term for emaciated is cachexia
• Inspecting the patient’s skin can reveal useful information via color changes, edema, and diaphoresis
• Skin color varies based on pigmentation, but nail beds and gums should be pink

Skin Appearance

• Pale appearance with cold, clammy skin can indicate shock or hypotension
• Angioedema involves swelling that may appear in the face, tongue, larynx, hands, or feet
• It may be caused by an allergic reaction such as a bee sting/insect bite, drug reaction, or food allergy
• Diaphoresis, or excessive sweating, may indicate acute respiratory distress or cardiac disease (myocardial infarction, congestive heart failure)
• Sweating my result from fever, infection, certain drugs, anxiety, stress, pain, low blood sugar, or from alcohol/narcotic withdrawal

Assessing Skin Color

• Observe the patient's color
• Abnormal decrease in color, like ashen or pallor skin, may indicate anemia or acute blood loss
• Jaundice, or yellowing of the skin, indicates liver failure
• Erythema, or redness of the skin, may be due to capillary congestion, inflammation, or infection
• Ecchymosis, indicated by superficial bleeding under the skin, is common in the elderly
• Cyanosis presents as bluish discoloration of the skin, nail beds, and mucus membranes if there is elevated desaturated hemoglobin in the arterial blood
• Most readily observed areas for cyanosis include lips, gingiva (gums), and nail beds of the fingers and toes

Central vs Peripheral Cyanosis

• Central cyanosis appears on the trunk or oral mucosa
• Peripheral cyanosis appears on the hands, fingertips, and nail beds of the hands and feet
• To develop cyanosis, unsaturated Hb must exceed 4 to 5 g/dL
• A patient with a normal Hb (15 g/dL) will likely become cyanotic when oxygen saturation falls to <73% (i.e., 4 to 5 g/dL of desaturated Hb)
• Clinicians needs to differentiate if cyanosis is caused by a cardiac or respiratory problem
• Respiratory causes of cyanosis include hypoventilation and impaired gas exchange in the lung
• Cardiac causes include congenital cardiovascular anomalies leading deoxygenated blood shunting from right to left side of the heart and then pumped to the peripheral tissues
• A pale, cold, and clammy appearance might be as dangerous as cyanosis
• Skin rash combined with mucosal edema, nasal polyps, and aspirin intolerance that are common in allergic asthma indicate triad asthma
• Carbon monoxide poisoning leads to a bright cherry red skin color
• Glascow Coma Scale parameters include eye opening, verbal, and motor response
• It utilizes the Eye (4), Mouth (5), Arms (6) measurements
• Eyes: Spontaneous opening, verbal stimuli, to pain, none
• Mouth: Oriented, confused, inappropriate words, incoherent, none
• Arms: Obeys commands, localizes to pain, withdraws from pain, flexion to pain, extension to pain, none

Posturing

• Decorticate rigidity (flexor) involves having arms that move like "C's."
• It involves problems with the cervical spinal tract or Cerebral Hemisphere
• Decerebrate rigidity (extensor) involves having arms that move like "E's."
• It involves problems with the Midbrain or Pons
• When interviewing a patient, determine LOC (level of consciousness)
• Alert and responsive LOC- normal
• Lethargic, somnolent or sleepy LOC- consider OD or sleep apnea
• Stuporous or confused LOC- drug OD or intoxication
• Semicomatose LOC- responds to only painful stimuli
• Obtunded LOC- drowsy state, may have decreased cough or gag and is high risk
• Coma- the patient does not respond to any stimuli

Examination of Thorax

• Barrel chest is seen with emphysema and indicates poor lung recoil or increase in compliance
• Other signs of issues include skin retractions during inspiration and tracheal tugging
• Pectus carinatum is an abnormal sternum protrusion
• Pectus excavatum is an abnormal sternum depression
• Kyphoscoliosis is an abnormal spine curvature often causes severe restrictive lung disease

Patient Interview Questions

• Orient the patient to time, place, and person to check the patient's orientation

• Is well oriented, cooperative, and knows who people are

• Exhibits disorientation, confusion, or delirium

• Ask the patient to perform simple tasks or repeat instruction to assess their ability cooperate

• Name and date of birth are easy tasks to test cooperation

• You are always assessing the patient for mental status changes

• Inability to cooperate can be due to language difficulties, influence of medications, hearing loss, fear, apprehension, or depression Assess the emotional state of the patient -Anxiety/nervousness means asthmatic, respiratory distress, or hypoxemia -Depression presentation is quiet -Anger presentation is combative and irritable -Electrolyte imbalance might present itself as anger, combativeness, or irritability

• Patient who's euphoric exhibits drug overdose presentation (morphine)

• Patient who's panic is dealing with tension pneumothorax and status asthmaticus

• Introduce yourself & ask neutral questions in social space (~4-12 feet)

• Interview at personal space (~2-4 feet). Use appropriate level eye contact

• Assume physical position at same level as patient

• Avoid leading, open ended or closed questions. Use neutral, direct questions

Interview Questions

• Open ended questions encourages patients to describe events and priorities
• Closed questions focus on specific information
• Direct questions can be open ended or closed. Refrain from responding with one word because it could be intimidating
• Neutral questions are preferred for all interactions
• Dyspnea is breathing discomfort (subjective feeling). It is the most important symptom for a respiratory therapist to treat
• Orthopnea is difficulty breathing except when sitting upright. Might be cause of heart problem
• Platypnea is difficulty breathing in upright positions

Assessing Dyspnea

• Assessing dyspnea requires patient to describe feelings
• Patient to mention they cannot take deep breath
• What the cause of discomfort comes from
• Patients with CHF fluids lungs can be short of breath lying down
• There are patients with asthma is complaint of chest tightness
• Patient with CHF is feeling suffocated
• Psychogenic Dyspnea, panic disorders and hyperventilation
• Hypoxia, pain, temperature or panic

Cough Analysis

Assess the cough!

• Occurs when cough receptors in airways are stimulated by inflammation, mucus, foreign material, or noxious gases
• Located primarily in the larynx, trachea and larger bronchi
• Weak cough is often due to high Raw, poor lung recoil, weak muscles or pain
• Associated with restrictive lung diseases, CHF, or pulmonary fibrosis
• Loose productive cough is associated with bronchitis and asthma Causes- asthma, postnasal drip, bronchitis, GERD and cardiac meds

Sputum Analysis

• Mucus from tracheobronchial tree free of oral secretion is called "phlegm"*
• Mucus from lower airways through mouth is called "sputum"*
• WBC/ puss cells is said to be "purulent"*
• Foul smelling sputum is "fetid."*
• Recent change of sputum color, viscosity or quantity is an infection (tell doctor).* Moved to hypopharynx by mucociliary transport escalator where there it is swallowed or expectorated.

Sputum

• Coughing up blood = hemoptysis Blood-streaked is a patient with chronic lung disease
• Fresh hemoptysis *
• Amount expectorated = massive
• Massive sputum amount in a day over 300 ml
• Small sputum amount non-massive

Important Considerations

• Assess Sputum - small, moderate, large, copious and color that is thin, thick or tenacious.*
• Sputum culture = identify what is the present bacteria within this sputum. *
• Gram / Acid = classify bacterium as positive or negative in a sputum stain*

Types of Pain

• Somatic pain comes from the skin, muscles, tissues, bones, ligaments, or tendons
• Visceral pain comes from cavities due to ischemia, inflammation, or injury
• Neuropathic pain occurs because of a nerve injury
• Pain intensity rating scale is numbered 0-10
• Rating from 0-3 is mild
• Rating from 4-7 is moderate
• Rating from 8-10 is severe
• Burning and hot pain may be neuropathic
• Patients with cardiopulmonary disease may experience generalized and localized pain due to specific injury or disease.
• Chest pain patients are a common and wide variety problem as heart disease, pneumonia, pleurisy, rib fracture

Intake and Output

• Causes of pain include tissue damage, trauma, surgery, and medical procedures, intensive care units or multiple invasive lines and subject to unpleasant procedures.
• Pain and anxiety occurs in the ICU patient can result increase metabolism and fighting ventilator because there are a multiple issues in ICU.
• Rate patient pain as a scale 0-10 with worst case pain

Types of Chest Pain

• Pleuritic chest pain-located laterally or posteriorly and described as sharp, increases with pneumonia & pulmonary embolism-
• Non-pleuritic chest pain- located in center of the anterior chest and caused in coronary artery disease
• Hyperthermia aka febrile indicates Elevation of body temperature
• Hyperthermia symptoms is a body temperature that can lead to storming or a infection airway in the lungs
• Hypothermia can cause a reduces of 02 consumption, or reduction of HR and breathing and known as “Code Cool”
• 40ml/hour is normal urine
• Electrolyte imbalance comes issues with intake or output

Edema

• Pedal edema causes an increase vessels issue
• Indicates severe swelling
• pitting Edema mark is when pressure is applied is when fluid leaks at point pressure
• The cause of Swollen ankles is related to heart failure. Normal beats is a 60-100 per min
• assess for heart, shock ,low vs high
• The disease results due to the body tries to compensate by increasing the HR to increase cardiac output

Pulse Readings

• Increased pulse (HR) is called tachycardia
• Assess for hypoxemia, anxiety, and stress
• Decreased Pulse (HR) is called bradycardia
• Pulses paradoxus (or paradoxus pulse) is a decrease in BP >10 mmHg during inspiration
• During respiratory distress, the inspiratory efforts affect the function
• Measured by blood pressure cuff
• Common in acute COPD, asthma, cardiac tamponade, restrictive pericarditis
• Normal respiratory is 12-20 per minute adult*

Tachypnea and Bradypnea

• Apnea- no respiration and call it respiratory arrest!*
• Is RR that is greater than 20 (tachy)*
• is RR that is less than 12.*(brady)
• Is increase RR depth and regular rhythm call it- hyperpnea*
• Is increased depth and cycle Apnea- Cheyne-Stokes*
• Cessation call Code blue- Apnea*
• Prolonged inspiration-Apneustic.*
• Is increase depth and labor breathing sounds- kussmuals with cause if DKA*

Factors Affecting Blood Pressure

• Three different Factors can Affect BP
• Heart as a pump that increases/decreases BP
• HR/Strength will Affect the pressure levels
• Excessive fluids increases the pressure while loss/dehydration decreases the pressure-Blood and vessel conditions (constriction vs dilation) change BP.
• Shock- the body is not working or getting enough delivery in organs*
• Cardiac shock- the ventricles or heart is not pumping or moving.*

Head and Neck Exam Notes

The trachea should be midline, or in some cases can shift with something in this airway. Jugular venous distention is seen in patients with CHF and cor pulmonale. * Vocal sounds, fremitus is increased with pneumonia and atelectasis*

• Vocal fremitus in reduced with emphysema vs consolidation.*
• In chest palpation you need to repeat (99) *

Breath Sounds

Hear air filled lung versus hollow sounds call is Resonant!

• Hear fluid lungs ( pneumonia vs congestive heart failure) call dull or flat air.* Heard in lungs where there pneumothorax= booming sound

Auscultation

• Vesicular is normal in lungs ( bilateral and bronchial is normal when you have two lungs.
• The comparison of lungs has to start same level from side to side. .
• Pectoriloquy (whisper the letter E can means consolidation)
• bronchial Is abnormal
• Vesiculation indicates density increase
• COPD indicates diminished breath sounds at site ( shallow or slow breathing).
• Walls means you are in (asthma ♻️ COPD)
• Wheezes indicate the consistency of multiple airway with more obstruction and sounds

Sounds of Respiratory Distress

• Upper emergency airway=Constant pitch with monophonic
• Marked stridor can cause emergency like intubation

Crackles

• Coarse is needing Section in airways when moving fluids throughout airway= Crackles-
• Fine indicates in lung/deep breathing/ congestive lungs= Crackles. Digital and interstitial diseases are variety conditions of examination
• Digital clubbing indications is various lungs issues.

Questions cover concepts of fluid intake/output imbalances, edema, heart rate variations, and sputum analysis. It also tests knowledge on physiological processes and assessment findings related to respiratory and cardiovascular health. Includes identifying conditions based on sputum color and volume.