Patient Assessment PDF

Bedside Assessment of the Patient  4 Critical Life Functions Ventilation: moving air in and out of the lungs RR, chest movement, breath sounds, PaCO2, etc.. Oxygenation: getting oxygen into the blood HR, color, sensorium, PaO2, etc.. Circulation: moving the blood th...

Bedside Assessment of the Patient  4 Critical Life Functions Ventilation: moving air in and out of the lungs RR, chest movement, breath sounds, PaCO2, etc.. Oxygenation: getting oxygen into the blood HR, color, sensorium, PaO2, etc.. Circulation: moving the blood through the body Pulse, HR and strength, cardiac output Perfusion: getting blood and oxygen into the tissues Blood pressure, sensorium, temp, urine output, hemodynamics 2 Monitoring Life Functions Almost every part of the assessment relates to one of the items listed previously If the patient is showing ANY signs of problems with one of these you must treat/correct right away If you go in to do a breathing treatment and your patient is diaphoretic don’t give the treatment, STOP and assess, call rapid response if necessary, If patient is desating, don’t start the treatment until you stabilize the patient, either start oxygen therapy or increase oxygen therapy. Call a rapid response if needed. If any of the four items previously listed is absent – call a code blue First priority: Ventilation: Establish open airway and breathe Oxygenation: increase FIO2 Circulation: chest compressions, drugs, etc. Perfusion: increase blood pressure 3 Reviewing Patient’s records Admission notes: Admitting diagnosis, history of present illness, chief complaint, past medical history Signs and symptoms: Signs: objective information – those things you can see OR measure. (color, pulse, edema, blood pressure, etc..) Symptoms: subjective information, those things that the patient must tell you (dyspnea, pain, nausea, muscle weakness, etc..) Occupation or employment history - why is this important? Allergies or allergic reactions – especially medications and dyes Prior surgery, illness, injury 4 Reviewing Patient’s Records (cont.) Vital signs: respirations, pulse, BP, temp Physical exam of chest (inspection, A/P diameter, palpation, percussion, auscultation) Smoking history Pack years = # of packs per day times the # of years smoked Example = smoked 2 packs per day times 20 years = 40 pack year history Advance Directives, code status 5 Patient Evaluation Respiratory Orders: type of treatment, frequency & meds Patient Progress notes: Respiratory records date, time (24 hour clock), reactions, etc.. Nursing notes: check patient status Admission notes – records pertinent patient data Physician notes: If change in patient condition, check corresponding respiratory orders Lab reports ABG, CBC, BUN, Creatinine, Troponins, etc., PFT, x-rays, CT, MRI, etc.. 6  General Appearance The first step is to observe the patient’s general appearance when beginning a physical exam. The goal is to gain a picture of the individual as a whole. And our documentation should reflect that picture. If I read you documentation could you see that picture in your mind? Inspection of the patient should begin at the moment the clinician first encounters the patient and continue throughout the assessment. Gender, ethnicity, age, height, weight, and general state of health should be noted. Facial expression may provide clues as to the patient’s emotional state. General appearance can also provide clues as to the patient’s nutritional status.  General Appearance Important questions to consider regarding the patient’s general appearance include: Is the patient awake, alert, and responsive? Is the patient relaxed and resting quietly? Is the patient anxious, restless, or disoriented and/or confused? What is the patient’s position (lying down, sitting up, other)? Are there any signs of respiratory distress? What ancillary equipment or supplies are in use (oxygen equipment, monitoring equipment, intravenous lines)? What is the patient’s general state of health?  General Appearance The patient’s general appearance, overall condition, level of consciousness, respiratory rate and pattern, and signs of respiratory distress should be noted. The respiratory clinician should note the patient’s color and if the patient is sweating excessively. Note patients’ Spo2, along with any supplemental O 2 the patient may be receiving. If cardiac monitoring equipment is in use, the clinician should note the cardiac rate and rhythm and observe for gross arrhythmias. The general inspection should include the head and face, neck, hands and fingernails, and skin of the arms and extremities. Emaciated patient. Very thin, ”wasting away” These patients have poor nutritional status and will be very weak. Very weak patients are may develop atelectasis, pneumonia, or both because they breath shallow. Another term used may be cachexia Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 10 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.  Skin Inspecting the patient’s skin in order to detect changes in skin color and the presence of edema or diaphoresis provides useful information. Skin color varies with skin pigmentation; however, the nail beds of the fingers, toes, and the gums should be pink. A pale appearance, with cold, clammy skin is associated with shock or hypotension. Angioedema is swelling that may appear in the face, tongue, larynx, hands, or feet. May be caused by an allergic reaction to a bee sting or insect bite, a drug reaction, or food allergy.  Diaphoresis Excessive sweating (diaphoresis) 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 and medications, anxiety and stress, pain, low blood sugar, and withdrawal from alcohol or narcotic drugs. This athlete is sweating because he is running up and down the basketball court. What if your patient is sweating like this but they are laying in bed and not moving? Think you have a problem? Assessing Skin Color Look at the patient’s color. Abnormal decrease in color (ashen, pallor) can be due to anemia or acute blood loss Jaundice is a yellowing of the skin. This indicates liver failure Erythema is redness of the skin. Could be capillary congestion, inflammation or infection Ecchymosis (ek-ee-mo-sis) superficial bleeding under the skin. Common to see in elderly Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 13 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.  Assessing Skin Color - Cyanosis Cyanosis is a bluish discoloration of the skin, nail beds, and mucus membranes caused by an elevated level of desaturated (deoxygenated) hemoglobin (Hb) in the arterial blood. Most readily 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. In order to develop cyanosis, the level of unsaturated Hb must exceed 4 to 5 g/dL. A patient with a normal Hb (15 g/dL) will probably become cyanotic when the oxygen saturation falls to < 73% (i.e., 4 to 5 g/dL of desaturated Hb).  Peripheral Cyanosis Central Cyanosis a nos i Cy s Clinicians should 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 in which deoxygenated blood is shunted from the right to left side of the heart and then Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 15 Other Alterations in Skin Color A pale, cold, clammy appearance may be 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. Eyes (4), mouth (5), arms (6) Eyes: Spontaneous opening 4, verbal stimuli 3, to pain 2, none 1 Mouth: oriented 5, confused 4, inappropriate words 3, incoherent 2, none 1 Arms: obeys commands 6, localizes to pain 5, withdraws from pain 4, flexion to pain 3, extension to pain 2, none 1 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 18 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Patient Interview Determine LOC Alert and responsive – normal Lethargic, somnolent, sleepy – consider OD or sleep apnea Stuporous, confused – drug OD or intoxication Semicomatose – responds to only painful stimuli Obtunded – drowsy state, may have decreased cough or gag **Risk** Coma – does not responds to painful stimuli Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 19 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Examination of Thorax Barrel chest—seen w/ emphysema; indicates poor lung recoil (or increase in compliance) 20  Retractions (skin sucks inward during inspiration) Tracheal tugging 21 Examination of the Thorax (cont..) Pectus carinatumabnormal protrusion of the sternum Pectus excavatumabnormal depression of the sternum Kyphoscoliosisabnormal curvature of the spine; often causes severe restrictive lung disease 22 Patient Interview Check orientation to time, place and person Well oriented, cooperative, knows who people are Disoriented, confused, delirious Ability to cooperate – ask to perform simple tasks, ask to repeat instructions. An easy one is to ask their name and date of birth (DOB). Every time we do a treatment we are assessing mental status changes. When you know your patient & they are not acting the same - question it! Inability to cooperate may be due to: Language difficulties Influence of medications Hearing loss Fear, apprehension, depression, etc.. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 23 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Patient Interview Assess emotional state Anxiety, nervousness –asthmatic, respiratory distress, hypoxemia Depressed – quiet Anger, combative, irritable – electrolyte imbalance Euphoria – drug overdose (morphine) Panic – hypoxemia, tension pneumothorax, status asthmaticus 24 Interviewing Technique Introduce yourself in social space (~4-12 feet) Interview in personal space (~2-4 feet) Use appropriate eye contact Assume physical position at same level as patient Avoid use of leading questions; use neutral questions Example: “Is your breathing better now?” OR “How is your breathing now?” Which one is more neutral? 25 Interviewing Open ended questions encourages patients to describe events and priorities as they seem them Closed questions focus on specific information like “when did your cough start?” Direct Questions can be open ended or closed. Try to stay away from responding with one word like “why?”. This can be intimidating to the patient Neutral questions are preferred for all interactions 26 Cardiopulmonary Symptoms Dyspnea Sensation of breathing discomfort by patient (subjective feeling) Most important symptom RT is called upon to assess & treat Orthopnea: Difficulty breathing except in upright position (heart problem, CHF) Platypnea: Difficulty breathing in upright position 27 Cardiopulmonary Symptoms How does the patient rate their SOB? 28 Cardiopulmonary Symptoms Dyspnea - Subjective experience. Should not be inferred from observing patient`s breathing pattern Assessing dyspnea should include patients describing what they are feeling. For example “When I take a deep breath in it feels like something is stopping me before I am finished.” Keying in on how the patient is describing the breath can help determine cause. Atelectasis, asthma, some kind of restriction, or obstruction, etc.. Why do patients with CHF (excess fluids) in the lungs feel SOB when laying down? Fluid shifts from lower extremities to lungs. There is a reduced pulmonary compliance 29 Cardiopulmonary Symptoms (cont..) Language of Dyspnea Ask patient about quality & characteristics of dyspnea (may provide insight into its causes) Patients with asthma frequently complain of chest tightness Patients with CHF may complain of feeling suffocated 30 Cardiopulmonary Symptoms (cont..) Psychogenic Dyspnea: Panic Disorders & Hyperventilation Patients have normal cardiopulmonary function of intense dyspnea & suffocation May coincide with symptoms, such as chest pain, anxiety, palpitation & paresthesia (tingling & numbness in extremities that occurs with respiratory alkalosis. Anxiety often accompanied by breathlessness & hyperventilation DO NOT ASSUME THAT ANY SOB IS ANXIETY RELATED. LOOK FOR THE UNDERLYING CAUSE i.e. hypoxia, pain, temp, etc.. 31 We must assess the cough! 32 Cardiopulmonary Symptoms (cont..) 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 associated with inflammatory obstructive diseases like bronchitis, asthma Causes of chronic cough: asthma, postnasal drip, chronic bronchitis, GERD. Certain ACE Inhibitor cardiac meds can cause cough. 33 Cardiopulmonary Symptoms (cont..) Sputum production 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 is it swallowed or expectorated. 34 Cardiopulmonary Symptoms (cont..) Hemoptysis Coughing up blood or bloody sputum from the lungs Blood-streaked is common in patient with chronic lung disease. Frank hemoptysis is primarily blood in the expectorant Characterized—massive or non-massive Massive More than 300 ml of blood expectorated over 24 hours Common causes: bronchiectasis, lung abscess, & acute or old tuberculosis Distinguished from hematemesis (vomiting blood from gastrointestinal tract) Non-massive Common causes include: infection of airway, tuberculosis, trauma, & pulmonary embolism 35 Sputum Analysis Amount of sputum: small, moderate, large, copious Consistency: thin, thick, tenacious Color: Clear – normal Mucoid – white/grey may indicate chronic bronchitis Yellow – presence of WBC and may indicate bacterial infection Green – stagnant sputum, may indicate gram negative bacteria (bronchiectasis, pseudomonas) Brown/dark – old blood Bright Red – hemoptysis (bleeding tumor, TB) Pink Frothy – pulmonary Edema 36 Sputum analysis Sputum culture Identify bacteria present Sensitivity Identify what antibiotics will kill the bacteria Gram stain Identify whether it is gram positive or gram negative Acid fast stain Identify mycobacterium TB 37  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 injury5 Pain Pain may also be acute or chronic, localized or generalized, and of varying quality and severity. Sharp, stabbing, localized pain is often somatic. Generalized pain (deep pain, aching, pressing or squeezing) is visceral in origin.5 Burning or hot pain may be neuropathic.5  Pain Patients with cardiopulmonary disease may experience generalized pain and discomfort or localized pain due to specific injury or disease. Chest pain is a common symptom in patients with a wide variety of cardiopulmonary problems ranging from heart disease to pneumonia, pleurisy, rib fracture, pneumothorax, and tumor. Abdominal pain can be caused by many different disease states and conditions including gastric or intestinal disease, reflux disease, appendicitis, and diverticulitis. Acute, intense abdominal pain with hemodynamic instability represents a medical emergency requiring immediate attention. Pain Causes of pain include tissue damage due to specific disease states, injury, trauma, surgery, and medical procedures. In the intensive care unit (ICU), patients may have multiple invasive lines and catheters and are subject to unpleasant or painful procedures. Control of pain and anxiety in the ICU patient is often inadequate and may result in hyper metabolism, increased O2 consumption and fighting the ventilator in patients receiving mechanical ventilatory support.18 Assessment of pain should be based on what the patient reports. A common method is to ask the patient to rate his or her pain on a scale of 0 to 10, where O indicates no pain and 10 indicates the worst possible pain. 18 Cardiopulmonary Symptoms (cont..) Chest pain Pleuritic chest pain—located laterally or posteriorly – described as sharp and stabbing pain, & increases with deep breathing (pneumonia & pulmonary embolism) Associated with diseases that cause pleural lining to become inflamed Nonpleuritic chest pain—located in center of the anterior chest & may radiate to shoulder or arm often caused by coronary artery disease & known as angina in such cases (other causes: gastroesophageal reflux & esophageal spasm, gallbladder disease) Stop and discuss this with your elbow partner. Explain and point out the difference where pleuritic pain the nonpleuritic pain is located 42 Cardiopulmonary Symptoms (cont..) Fever (hyperthermia) aka febrile Elevation of body temperature due to disease or sympathetic storming (“neuro storm”) due to brain injury May occur with simple viral infection of upper airway or with serious bacterial pneumonia, tuberculosis, & some cancers Causes increased metabolic rate, oxygen consumption & carbon dioxide production Hypothermia Reduces O2 consumption and CO2 production, may reduce HR and breathing “Code Cool” on MI patients 43  Patient Evaluation (cont.) Intake and output Normal urine output is 40 mL/hr. (approximately 1 Liter/day) Sensible water loss – urine, vomiting Insensible water loss – lungs and skin If intake exceeds output, this can result in: Weight gain Electrolyte imbalance Decreased lung compliance Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 44 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 45 Cardiopulmonary Symptoms (cont..) Pedal edema, most common with heart failure which causes an increase in hydrostatic pressure of the blood vessels in the lower extremities. This causes fluid to leak into the interstitial space which causes pedal edema Rated at +1, +2, +3, +4, higher indicates severe swelling Pitting edema—indentation mark left on skin after applied pressure Weeping edema—small fluid leak occurs at point where pressure applied Swelling of the ankles is most often due to heart failure. 46 Physical Examination (cont.) Pulses Pulse is evaluated for rate, rhythm and strength Normal is 60 – 100 beats per min Increased Pulse (HR) is called tachycardia Assess for hypoxemia, anxiety, stress Decreased Pulse (HR) is called bradycardia Assess for heart failure, shock Normally, most athletes and quadriplegic patients will have low heart rates which is normal for them. Pulmonary disease causes decrease in PaO2 and increased O2 consumption so the body tries to compensate by increasing the HR to increase cardiac output. 47 Physical Exam (cont.) Pulsus paradoxus (or paradoxical pulse) is a decrease in BP >10 mmHg during inspiration Measured by 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 http://youtu.be/jTsjCZ9QxW8 48 Physical Exam (cont.) Respiratory Rate Normal is 12 – 20 per minute for an adult Apnea – no respirations – Respiratory Arrest Tachypnea is a RR greater than 20 Fever, hypoxemia, metabolic acidosis, anxiety, pulmonary edema, lung fibrosis, pain Bradypnea is RR less than 12 Normal when sleeping Can occur in traumatic brain, hypothermia, meds, narcotics, 49 Physical Exam (cont.) 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 http://youtu.be/VkuxP7iChYY Agonal breathing http://youtu.be/88uCTEmuuGI 50 Breathing patterns Apnea: cessation of breathing – call a CODE BLUE 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 Causes: Problems with respiratory center, trauma, tumor https://www.youtube.com/watch?v=ViGjOiPE2mY&t=125s Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 51 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Blood Pressure (BP) Three factors control BP Heart Heart is a pump that creates BP. Changes in the heart will affect BP directly Increase HR/strength will increase BP Decrease in HR/strength will decrease BP Blood The amount in the system will affect BP Excessive fluids – increase pressure Loss of fluids – decrease pressure Vessels Conditions of the blood vessels causes changes in BP Vessel constriction – increase pressure Vessel dilation – decreases pressure Changes in hemodynamic measurements would indicate that one of these three factors has changed 52 Vital Signs (VS) 53 Blood Pressure (BP) cont.. Shock: Inadequate delivery of O2 and nutrients to the vital organs relative to their metabolic demand. Cardiogenic shock: Left ventricular failure caused by either hemorrhage or severe fluid loss Septic shock: Overwhelming infection. Vasodilation occurs which decreases blood pressure Orthostatic hypotension: Postural change which causes a quick decrease in blood pressure (usually hypovolemia is involved) 54 Head and Neck Exam (cont..) The trachea should be midline; it may shift left or right with upper lobe abnormalities or mediastinal tumors. Jugular venous distention is seen in patients with CHF and cor pulmonale. http://youtu.be/oka-hEH7Gzo 55 Chest Palpation - Fremitus Tactile vocal fremitus is increased with pneumonia and atelectasis. Tactile fremitus in reduced with emphysema, pneumothorax, and pleural effusion. Rhoncial fremitus – secretions in the larger airway Stop and PRACTICE: Repeat the numbers 99, 99, 99 as you move your hands 56  Chest Percussion Resonant – normal, air filled lung (gives hollow sound) Flat – heard over sternum, muscles, or areas with atelectasis Dull – heard over fluid-filled organs like heart or liver. Pleural effusions or pneumonia will give this thudding sound Tympanic – heard over air-filled stomach. Hyperresonant- found in lung where Stop and Practice, please no talking for pneumothorax or emphysema is present a moment so (booming sound) everyone can hear Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 57 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Breath sounds Normal breath sounds = vesicular Bilateral vesicular sounds – normal sounds in both lungs (assuming they have two lungs) Bronchial breath sounds – normal sounds heard over the trachea or bronchi Compare one side with the other, start at the lower lobes (see next slide) Egophony – the patient is instructed to say “E” and it sounds like “A”, which would indicate consolidation (like pneumonia) Whispered pectoriloquy-pg.175 58 Time to practice! Listen to full inhalation and exhalation. How long does it take to get air in? How long does it take to get air out? Does it sound different on inspiration that expiration? https://www.easyauscultation.com/ 59 Chest Auscultation (cont..) Bronchial breath sounds Abnormal if heard over peripheral lung regions Replacing normal vesicular sounds when lung tissue density increases Diminished breath sounds Occur when sound intensity at site of generation (larger airways) is reduced due to shallow or slow breathing, or hyperinflation When sound transmission through lung or chest wall is decreased (COPD or asthma) 60 Chest Auscultation (cont..) Wheezes are Consistent with airway obstruction like asthma and COPD Polyphonic wheezing, multiple sounds Unilateral may indicate foreign body obstruction Stridor Upper airway obstruction monophonic wheezing, constant pitch marked stridor = airway emergency so don’t wait, INTUBATE Supraglottic swelling (epiglottitis) Subglottic swelling (croup or extubation) 61 Chest Auscultation (cont..) Coarse crackles (aka rhonchi) LARGE airway secretions, patient needs suction Air moving through fluid in the airway Usually clears when patient coughs or upper airway is suctioned 62 Crackles Fine crackles/rhales Sudden opening of small airways in lung deep breathing Heard w/ CHF, pulmonary edema & atelectasis Treat with heart drugs, diuretics and oxygen 63 Examination of Extremities Digital clubbing - seen in large variety of chronic conditions: congenital heart disease, chronic bronchitis, various cancers, & interstitial lung diseases 64