Patient Assessment 2024a.ppt

Assessment Bedside Assessment of the Patient  Terms SOA: Shortness of air WOB: Work of breathing Dyspnea: SOA as perceived by the patient Orthopnea: SOA laying flat Platypnea: SOA sitting up or upright Angina: Chest pain Pedal Edema: S...

Assessment Bedside Assessment of the Patient  Terms SOA: Shortness of air WOB: Work of breathing Dyspnea: SOA as perceived by the patient Orthopnea: SOA laying flat Platypnea: SOA sitting up or upright Angina: Chest pain Pedal Edema: Swelling of the lower extremities  Sputum Terms Phlegm: Mucus from the lungs that has been contaminated with oral secretions Sputum: Mucus from the lungs that pass through the mouth Purulent: Sputum that contains puss Fetid: Foul smelling Mucoid: Clear and thick Hemoptysis: Coughing up blood or blood streaked sputum. Sputum Characteristics  THE PROCESS Receive Report Review Patient’s Chart Verify Orders History and Physical Recent Assessments  SOAP NOTES S subjective What the patient feels O objective observation, palpation, percussion & auscultation findings ; include HR, BP,SO2, CXR &ABG results A analysis of all the subjective & objective findings= problems to be treated P plan What is the physicians plan of treatment Rx treatment performed and effectiveness  Your Assessment Begins when you enter the patients room. Appearance - how do they look Oxygen? - wearing on or off Communication - how well can they communicate Signs of Shortness of Breath ( SOB SOA) Work of breathing Clubbing? Initially: What you see and hear  Introduction Social Space Personal Space Properly Identify Self and Purpose Properly Identify the Patient Two forms of ID – Medical record Number – DOB – Name DO NOT USE ROOM NUMBER  Interviewing The Patient Closed ended questions: When did your symptoms start? Open ended questions examples: What is wrong? How do you feel? Closed or Open: Can you tell me how you feel?  Other Observations Body Position: Slumped over, Tripodding (posturing) Skin: Color ( pale, yellow, blue) Use of accessory muscles: WOB Level of Consciousness: Oriented x 3 to (person, place, time)  Sign of Abnormal Breathing Rate slower than 8 per minute or faster than 27 per minute Muscle retractions above clavicles, between ribs and below rib cage (especially in children) Pale or cyanotic skin Shallow or irregular Pursed lips Nasal flaring: Infants  LOC (level of consciousness) Lethargic: sleepy arouses easily responds well Obtunded: awakes with difficulty responds well after awake Stuporous: Does not awaken completely responds slowly responds to pain Comatose: unconscious, does not respond to pain stimuli Terms  Vital Signs Temperature : 37 C 98.6 F Blood Pressure: Normal between 120/80 mmHg and 130/90 mmHg – Hypertension : > 145/90 mmHg – Hypotension : < 90/60 mmHg – Postural Hypotension :  5mmHg from lying to sitting or standing Pulse Pressure: normal 30 to 40 mmHg Heart Rate – Tachycardia = HR> 100bpm – Bradycardia = HR < 60 bpm PAIN SCALE 1-10  Vital Signs Respiratory Rate: normal 12 – 20 breaths/min – Tachypnea : > 20 breaths/min (28 or GREATER***) – Bradypnea : < 10 breaths/min (8 or LESS***) Oxygen Saturations : > 90% or physicians orders Fluid output: >30ml/hr Pain: Known as the 5th Vital sign. Rated as perceived by the patient (scale 1 – 10). 5 Rights to Medication Delivery Right Patient Right Time Right Medication Right Dose Right Route  Technique for Respiratory Exam NEED ORDERLY PROCESS Before beginning, if possible: Quiet environment Proper positioning (patient sitting for posterior thorax exam, supine for anterior thorax exam) Bare skin for auscultation Patient comfort, warm hands and diaphragm of stethoscope, be considerate of women (drape sheet to cover chest) Inspect Palpate Percuss Auscultate Cyanosis = Less than 5gm% saturated Hb  Jugular Venous Pressure Think Cor Pulmonale Right Heart Failure Pulmonary HTN Normal , increased, and Markedly increased Thorax and Lung Inspection Pectus Carinatum Pectus Excavatum  Thorax Configuration Abnormalities Thorax Configuration Abnormalities Air Trapping Breathing Pattern Palpation of the Chest  Percussion Left hand on chest wall Middle finger of the left hand struck over the DIP tap it with middle finger of right hand Percuss top to bottom, compare both sides  Diagnostic Chest PERCUSSION Normal resonance - aerated lung Dull resonance - consolidated lung Stony dull resonance - pleural effusion Increased resonance – pneumothorax  Auscultation Points 12 anterior locations 14 posterior locations Auscultate symmetrically Should listen to at least 6 locations anteriorly and posteriorly  Auscultation Points Green Right Yellow Left Pink Left lower Purple Right lower Upper lobe upper Lobe Lob lobe Orange Right Middle lobe  Breath Sounds Normal Adventitious Tracheal Crackles (Rales) Bronchial Wheeze Bronchovesicular Rhonchi Vesicular Stridor Abnormal Pleural Rub Absent/Decreased Bronchial  Normal Breath Sounds Created by turbulent air flow Inspiration Air moves to smaller airways hitting walls More turbulence, Increased sound Expiration Air moves toward larger airways Less turbulence, Decreased sound Normal breath sounds Loudest during inspiration, softest during expiration  Normal Breath Sounds Tracheal Very loud, high pitched sound Inspiratory = Expiratory sound duration Heard over trachea Bronchial Loud, high pitched sound Expiratory sounds > Inspiratory sounds Heard over manubrium of sternum If heard in any other location suggestive of consolidation  Normal Breath Sounds Bronchovesicular Intermediate intensity, intermediate pitch Inspiratory = Expiratory sound duration Heard best 1st and 2nd ICS anteriorly, and between scapula posteriorly If heard in any other location suggestive of consolidation Vesicular Soft, low pitched sound Inspiratory > Expiratory sounds Major normal BS, heard over most of lungs  Transmitted Voice Sounds If abnormally located bronchial or bronchovesicular breath sounds assess transmitted voice sounds with stethoscope Ask the patient to say “Ninety-nine”, should normally be muffled, if heard louder and clearer this is bronchophony Ask the patient to say “ee”, should normally hear muffled long E sound, if E to A change this is egophony Ask the patient to whisper “Ninety-nine”, should normally hear faint muffled sound, if louder and clearer sounds are heard this is whispered pectoriloquy Increased transmission of voice sounds suggests that air filled lung has become airless  Adventitious Breath Sounds Wheeze Crackles (Rales) Rhonchi Stridor Pleural Rub Wheeze  Adventitious Breath Sounds CRACKLES - INSPIRATION May be early or late Possible causes of late – Low lung volumes Early – reopening of – Atelectasis larger airways – Pneumonia – Pulmonary oedema Late – reopening of small – Lung fibrosis peripheral airways and alveoli  Adventitious Breath Sounds CRACKLES - EXPIRATION May be early or late Early – sputum in more central airways Late – sputum in more peripheral airways Note: – Absence of exp crackles does note necessarily mean absence of secretions, as crackles are only heard if velocity of airflow is adequate and breath sounds audible  Adventitious Breath Sounds Rhonchi Similar to wheezes Low pitched, snoring quality, continuous, musical sounds Implies obstruction of larger airways by secretions Associated condition acute bronchitis  Adventitious Breath Sounds Stridor Inspiratory musical wheeze Loudest over trachea Suggests obstructed trachea or larynx Medical emergency requiring immediate attention Associated condition inhaled foreign body  Adventitious Breath Sounds Pleural Rub Discontinuous or continuous brushing sounds Heard during both inspiratory and expiratory phases Sounds like leather rubing against leather Occurs when pleural surfaces are inflamed and rub against each other Associated conditions pleural effusion, PTX  Adventitious Breath Sounds Diminished / Absent Breath Sounds Bronchial Breath Sounds