Week 3 RCP: Patient Assessment

Life Functions

• Crucial life functions monitored include ventilation, oxygenation, circulation, and perfusion.
• Ventilation involves the movement of air in and out of the lungs, assessed by respiratory rate (RR), chest movement, breath sounds, and PaCO2 levels.
• Oxygenation refers to oxygen uptake into the blood, evaluated via heart rate (HR), skin color, responsiveness, and PaO2.
• Circulation involves blood movement throughout the body, gauged by pulse rate and strength, heart rate, and cardiac output.
• Perfusion assesses blood and oxygen delivery to tissues, evaluated through blood pressure, responsiveness, temperature, urine output, and hemodynamic parameters.

Monitoring Life Functions

• Assessments directly relate to these vital functions.
• Urgent action is needed if patient shows signs of problems in any of these areas.
• Stop treatments like breathing treatments if the patient is excessively sweating (diaphoretic); assess, call rapid response, and seek immediate medical intervention.
• Stabilize the desaturating patient before starting a treatment. Use oxygen. Call rapid response as needed.
• If any life function is absent, call a code blue immediately.

Reviewing Patient Records

• Admission notes include the admitting diagnosis, medical history, and patient complaint.
• Signs are objective observations (color, pulse, edema, blood pressure).
• Symptoms are subjective experiences reported by the patient (dyspnea, pain, nausea).
• Employment history, allergies, prior treatments, surgeries, illnesses, and injuries are important factors to note.
• Vital signs (respiration rate, pulse, blood pressure, temperature) are crucial.
• Physical examination of the chest, including inspection, palpation, percussion, and auscultation, aids in assessing lung function.
• Smoking history (pack years) is important for evaluating potential risks and complications.
• Advance directives and code status documentation are essential.

Patient Evaluation

• Respiratory orders detail treatments, frequencies, and medications.
• Progress notes track respiratory issues, reactions, and changes.
• Nursing notes report patient condition monitoring.
• Admission notes supply pertinent medical data.
• Physician notes document any changes in the patient's condition that lead to alterations in respiratory orders.
• General appearance and overall condition are observed immediately. This should immediately highlight the patient's emotional state.
• Identifying data such as gender, ethnicity, age, height, and weight should be noted. Nutritional status is an important component.

General Appearance & Condition

• The patient's general appearance, overall condition, level of consciousness, breathing rate, respiratory patterns, and any signs of respiratory distress should be observed and documented.
• Document skin color and any signs of excessive sweating.
• The clinician needs to note the patient’s oxygen saturation (SpO2) and supplemental oxygen use.
• If cardiac monitoring is present, the heart rate and rhythm should be logged, along with any significant arrhythmias.
• A complete inspection should also encompass the head and face, neck, hands and nails, skin of the arms and extremities.

Patient Appearance - Emaciation

• An emaciated patient is extremely thin; wasting away.
• This indicates poor nutrition, which can further increase the risk of atelectasis, pneumonia, and other respiratory problems.

Skin Assessment

• Skin color varies with pigmentation; healthy nail beds, fingers, toes and gums should appear pink.
• Pale color with cold, clammy skin may suggest shock or hypotension.
• Swelling in the face, tongue, larynx, hands, or feet (angioedema) could indicate an allergic reaction.

Diaphoresis

• Excessive sweating (diaphoresis) could signal respiratory distress or cardiac issues (e.g., myocardial infarction or congestive heart failure), infection, fever, drug reactions, anxiety, or acute distress..

Skin Color Assessment

• Abnormal decrease in color (pale skin) may indicate anemia or acute blood loss.
• Jaundice is yellowing of the skin, which could reflect liver dysfunction.
• Erythema is redness of the skin due to capillary congestion, inflammation or infection.
• Ecchymosis is superficial bleeding under the skin, common in older patients.

Skin Color Assessment - Cyanosis

• Cyanosis is a bluish discoloration of the skin caused by desaturated hemoglobin.
• It's most noticeable in lips, gums, and nail beds.
• Central cyanosis appears in the mouth and trunk; peripheral cyanosis in hands and feet.
• Cyanosis typically develops when the level of unsaturated hemoglobin exceeds 4–5 g/dL.
• The cause of cyanosis should be differentiated between cardiac and respiratory problems.

Skin Color Assessment - Other

• Skin rash combined with mucosal edema, nasal polyps and aspirin intolerance sometimes indicate allergic asthma.
• Carbon monoxide poisoning may cause bright cherry red skin.

Patient Interview - Level of Consciousness

• Assess the patient's level of consciousness (LOC) through orientation to time, place, and person.
• Normal awareness, responsiveness, & cooperation (e.g., correctly answering simple questions like name & DOB) indicate a healthy state of mind.
• Lethargy, confusion, stupor, obtundation, and coma signify various degrees of diminished consciousness. These can be caused by medication overdoses, intoxication, sleep apnea, or brain injury.

Examination of the Thorax

• Barrel chest is associated with emphysema, indicating impaired lung recoil.
• Retractions (inward pulling of the skin during inspiration) and tracheal tugging indicate respiratory distress.
• Pectus carinatum and pectus excavatum are abnormal chest wall deformities.
• Kyphoscoliosis is curvature of the backbone, often causing restrictive lung problems.

Patient Interview - Emotional State

• Note anxiety or nervousness, depression, anger, irritability, euphoria, or panic, as these might point to particular conditions.

Interviewing Technique

• Maintain an appropriate social distance and ensure a comfortable environment for the interview.
• Apply interviewing techniques that are open-ended and closed-ended.
• Use neutral, and respectful communication for direct questions and encourage detailed responses. Avoid responding using only single words or leading questions.

Cardiopulmonary Symptoms - Dyspnea

• Dyspnea is difficulty breathing.
• Orthopnea is difficulty breathing while lying down.
• Platypnea is difficulty breathing in an upright position.

Cardiopulmonary Symptoms - Dyspnea (cont)

• Subjective responses from patients describe the feeling of dyspnea. Assess the patients' breathing patterns and reactions. Note the cause of the dyspnea.

Cardiopulmonary Symptoms - Dyspnea (cont) - Psychogenic Dyspnea

• Psychogenic Dyspnea can be caused by panic disorders or hyperventilation.
• The patient reports intense dyspnea (breathing discomfort), but the cardiopulmonary function is normal. The patient may complain of chest pain anxiety, palpitation and paresthesia(tingling).
• Do not assume that any shortness of breath is anxiety-related.
• Evaluate underlying causes (hypoxemia, pain, temperature, etc.).

Cardiopulmonary Symptoms - Cough

• Coughs are triggered by inflammations of the airways, mucus, or foreign bodies.
• Coughs are classified as productive (sputum) or nonproductive (dry).
• Common causes of chronic coughs include asthma, postnasal drip, bronchitis, and GERD.

Cardiopulmonary Symptoms - Sputum Production

• Sputum refers to the expectorated mucus from the airways, not saliva.
• Sputum quality describes its consistency, color, and amount.
• Sputum analysis includes evaluating its consistency, color.
• Changes in sputum quality can indicate infections.

Cardiopulmonary Symptoms - Hemoptysis

• Hemoptysis is coughing up blood.
• It can be massive (over 300 mL in 24 hours) or non-massive.
• Common causes include bronchiectasis, lung abscess, and tuberculosis..
• Hemoptysis needs to be distinguished from hematemesis (vomiting blood).

Sputum Analysis

• Color variations of sputum provide valuable clues about potential conditions (clear, mucoid, yellow, green, brown/dark/ or bright red).
• Use different stain methods (Gram Stain, Acid fast stain) to identify bacteria, or mycobacteria, like TB.

Pain

• Pain can be somatic (from skin, muscle), visceral (from internal organs), or neuropathic (from nerve injury).
• Types of pain include sharp, stabbing pain, generalized pain, burning, aching pain or a pressing pain.

Causes and Types of Pain

• Pain in people with cardiopulmonary diseases can be widespread or localized.
• Chest pain is common in many cardiopulmonary conditions (heart disease, pneumonia, pleurisy, rib fracture, pneumothorax, and tumors).
• Abdominal pain can be caused by various issues like gastric disease, reflux, appendicitis, or diverticulitis.

Pain Assessment

• Assess the patient's pain through self-reporting, using a 0-10 pain scale.
• Differentiate between pleuritic (sharp, stabbing) and nonpleuritic (central chest or radiating) chest pain.

Fever (Hyperthermia)

• Fever (hyperthermia or febrile state) is elevated body temperature caused by infection or neurologic causes.
• This increase in temperature increases oxygen demand.
• Hypothermia reduces oxygen and carbon dioxide production, dropping the respiratory rate and heart rate.

Intake and Output

• Normal urine output is approximately 1 liter (40 mL/hr) per day.
• Intake exceeding output causes potential weight gain and electrolyte imbalances.

Pedal Edema

• Pedal edema (swelling in the feet) is common in heart failure, as increased hydrostatic pressure leads to fluid leakage.
• Pitting edema is marked by an indentation after pressure; weeping edema involves fluid leakage.

Pulses

• Pulse evaluation includes rate, rhythm, and strength. (60–100 bpm).
• Tachycardia is an elevated heart rate; bradycardia is a decreased rate.
• These changes can reflect various conditions like hypoxemia, anxiety, stress, heart failure, or shock.
• Normal heart rate for patients like athletes and certain conditions is also normal.

Physical Exam - Pulsus Paradoxus

• Pulsus paradoxus is a decrease in blood pressure during inspiration, common with acute COPD, asthma, cardiac tamponade ,and restrictive pericarditis.
• This occurs because vigorous inspiration decreases left ventricular contraction.

Respiratory Rate

• Normal respiratory rate is 12–20 breaths per minute.
• Apnea (cessation of breathing) and respiratory arrest are critical conditions.
• Tachypnea (RR > 20) occurs with infection, hypoxemia, anxiety, pulmonary edema, lung fibrosis.
• Bradypnea (RR < 12) occurs during sleep, or with traumatic brain injuries, hypothermia, medications, and narcotic use.

Breathing Patterns

• Different breathing patterns are associated with different conditions (Apnea, Biot's, Kussmaul's, Apneustic).

Blood Pressure

• Blood pressure is influenced by the heart, amount of blood, and vessel condition.
• Shock is inadequate oxygen and nutrient delivery to vital organs.
• Cardiogenic shock results from left ventricular failure.
• Septic shock is triggered by overwhelming infections.

Head and Neck Exam

• Trachea should be midline, any shifts may indicate abnormalities.
• Jugular venous distension is a sign of heart failure.
• Look at the whole patient.

Chest Palpation – Fremitus

• Increased tactile vocal fremitus indicates pneumonia or atelectasis.
• Reduced fremitus may suggest emphysema, pneumothorax, or pleural effusion.
• Rhonchial fremitus is associated with secretions in larger airways.

Chest Percussion

• Resonant, flat, dull (fluid),and tympanic percussion sounds are used to assess lung sounds and possible infections.
• hyperresonance signifies air trapping (pneumothorax or emphysema).

Breath Sounds

• Normal breath sounds are vesicular sounds.
• Abnormal sounds (e.g., bronchial breath sounds in peripheral lung regions, diminished or absent sounds, other types of abnormal sounds) indicate various conditions.

Chest Auscultation – Wheezes & Stridor

• Wheezes (polyphonic or unilateral) indicate airway obstruction (asthma, COPD, or foreign body).
• Stridor is a high-pitched, monophonic wheeze that points to upper airway obstruction (epiglottitis, croup, post-extubation swelling)

Chest Auscultation - Crackles

• Coarse crackles are due to larger airway secretions and may be cleared by suctioning. Fine crackles are due to small airway opening and are caused by Congestive Heart Failure, pulmonary edema, and atelectasis.
• Treat with heart drugs, diuretics, and oxygen.

Examination of Extremities – Digital Clubbing

• Digital clubbing is associated with various chronic conditions (congenital heart disease, chronic bronchitis, cancer, and interstitial lung diseases).