Bedside Assessment of the Patient pdf.pdf

Bedside Assessment of the Patient The Medical Record and Medical History The first priority of the RT reviewing the medical record is to ensure that all respiratory care procedures are supported by a physician order that is current, clearly written, and complete Then review the...

Bedside Assessment of the Patient The Medical Record and Medical History The first priority of the RT reviewing the medical record is to ensure that all respiratory care procedures are supported by a physician order that is current, clearly written, and complete Then review the patient’s medical record by reading about current medical problems. The Medical Record and Medical History Familiarizes clinician with patients’ condition Reviewing patient’s chart:  Chief complaint (CC)/ history of present illness (HPI)  Explains current medical problems  Past medical history (PMI)  Smoking history is often recorded in pack-years  Packs smoked per day × number of years smoked  Family/Social/Environmental history  Potential genetic or occupational links to disease and the patient’s current life situation  Review of systems (ROS)  Advance directive Handwashing How to properly wash hands:  ~Wet hands with warm or cold water and apply soap  ~Rub hands together to make a lather and scrub them well; be sure to scrub back of hands, between fingers, and underneath fingernails  ~Continue rubbing for at least 20 seconds; Hum happy birthday song from beginning to end twice  ~Rinse your hands well with water  ~Dry hands using clean towel/paper towel; turn faucet off with paper towel *Alcohol based gels  ~Make sure use sufficient amount of gel and cover all surfaces of hands and fingers and rub hands together for at least 15 seconds before hands are dry Interviewing the Patient and Taking a Medical History Purposes  To establish a rapport between the clinician and patient  To obtain information essential for making a diagnosis  To help monitor changes in the patient’s symptoms and response to therapy Principles of Interviewing Interviewing is the process of gathering relevant information from a patient  An essential element of which involves establishing rapport Factors affecting communication between the RT and the patient include the following:  Sensory and emotional factors  Environmental factors  Verbal and nonverbal components of the communication process  Cultural and other internal values, beliefs, feelings, habits, and preoccupations of both the RT and the patient Structure and Technique for Interviewing 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 Typical Format for Recording the Physical Examination Initial Impression Vital Signs Head, Ears, Eyes, Nose and Throat (HEENT) Neck Thorax Abdomen Extremities General Clinical Presentation Begins moment you see patient & continues throughout exam Indicators to assess:  Level of consciousness  Facial expression  Level of pain, anxiety or distress  Body  Height, Weight, Positioning  Personal hygiene Level of Consciousness (Sensorium) Level of consciousness and orientation to time, place, and person (oriented × 3) Reflects oxygenation status of brain Affected by poor cerebral blood flow (hypotension) If patient not alert—standard rating scale is used to objectively describe patient’s level of consciousness Glasgow Coma Scale  Motor function  Verbal function  Eye-opening response Vital Signs (VS) Easy to obtain and provide useful information about current health status Vitals provide first clue to adverse reactions to treatment Four classic vital signs  Temperature  Pulse  Respirations  Blood pressure Additional observations  Pulse oximetry  ECG monitoring  Clinical impression Frequency of Vital Signs Measurement Patient condition Type of disorder/severity Procedures, surgeries, treatments being performed Baseline measurement Usually every 4-6 hours Should patient condition change suddenly, obtain vitals immediately Trends in Vital Signs Isolated measurement provides limited information Normal vitals for patient depends on:  Age  Presence of chronic disease  Treatment protocols  View in relation to patient’s normal level or values typically obtained for them Trend = baseline + measurements over time Comparing Vital Sign Information Change in patient’s condition  Comparing changes in vitals, signs & symptoms  Establishing differential diagnosis Key to expert assessment  Constant awareness of change Difference between new and expert clinician:  Knowledge  Ability to assess Body Temperature Normal: 98.6° F (37.0° C), range ( 97 to 99.5 F) Hyperthermia (fever): Temperature Hypothermia: Temperature Can be measured at:  Mouth, Ear, Axilla, Temporal, or Rectum  Feeling skin is not accurate Temperature conversion  Fahrenheit & Celsius conversion ° F = (° C × 9/5) + 32 ° C = (° F – 32) × 5/9 Fever Elevation of body temperature due to disease (greater than 38.3°C; 101°F) May occur with simple viral infection of upper airway or with serious bacterial pneumonia, tuberculosis, and some cancers Causes increased metabolic rate, oxygen consumption, and carbon dioxide production Particularly dangerous in patients with severe chronic cardiopulmonary disease because it may cause acute respiratory failure Dissipation through sweating, peripheral vasodilation, hyperventilation Pulse (Heart Rate) Evaluate rate, rhythm, and strength Radial artery most common site to palpate Normal adult pulse rate is 60-100 beats/min Tachycardia: HR greater than100 beats/min Bradycardia: HR less than 60 beats/min Pulse Rhythm and Pattern Types of rhythm:  Regular  Regular irregular  Irregularly irregular is unfavorable finding Spontaneous ventilation can influence pulse strength, or amplitude  A slight decrease in pulse pressure is normally present with each inspiratory effort Pulsus paradoxus is a significant decrease in pulse strength (greater than 10 mm Hg) during spontaneous inspiration  Is common in patients with acute obstructive pulmonary disease, especially patients experiencing an asthma attack Pulsus alternans is an alternating succession of strong and weak pulses  Suggests left-sided heart failure and usually is not related to respiratory disease. Respiratory Rate (RR) Resting adult RR is 12 to 20 breaths/min Tachypnea greater than 20 breaths/min  Associated with exertion, fever, hypoxemia, hypercarbia, metabolic acidosis, anxiety, pulmonary edema, lung fibrosis, and pain Bradypnea less than 10 breaths/min  May occur with traumatic brain injury, severe myocardial infarction, hypothermia, anesthetics, opiate narcotics, and recreational drug overdoses Terms Commonly Used to Describe Breathing Patterns Medical Term Definition Apnea Absence of spontaneous ventilation Eupnea Normal rate & depth of breathing Bradypnea Less than normal rate of breathing Tachypnea Rapid rate of breathing Hypopnea Decreased depth of breathing Hyperpnea Increased depth of breathing with or without an increased rate Sighing respiration Normal rate & depth of breathing with periodic deep and audible breaths Intermittent breathing Irregular breathing with periods of apnea Measurement of Respiratory Rate Watching abdomen or chest wall movement When regular  Count for 30 seconds x 2 Assess depth and pattern Abnormal respiratory rate & pattern may indicate respiratory distress but can also be caused by pain, anxiety or metabolic problems  Blood Pressure (BP) Normal: 120/80 mm Hg Systolic pressure is the peak force exerted in the major arteries during contraction of the left ventricle  Systolic: 90 to 120 mm Hg Diastolic pressure is the force in the major arteries remaining after relaxation of the ventricles  Diastolic: 60 to 90 mm Hg Pulse pressure: difference between systolic and diastolic  Normal is 35 to 40 mm Hg Hypertension vs. Hypotension Hypertension: BP 140/90 mm Hg  Risk factor for heart, vascular, renal disease  Major modifiable factor for stroke, CAD, CHF, peripheral vascular disease Hypotension: Systolic BP 90/60 mm Hg or mean art. pressure 65 mm Hg  Clinically significant if it drops suddenly or associated with symptoms such as dizziness or fainting  Changes in posture may cause abrupt changes in blood pressure Measurement of Blood Pressure Cuffed applied to extremity (usually upper arm) and inflated When pressure in cuff exceeds systolic blood pressure, blood flow through artery is occluded and pulse can no longer be felt Cuff is gradually deflated and when pressure in cuff is equal to pressure in artery, the artery opens and the blood begins to return to the part of the artery that was closed. As blood returns to artery, pulse sounds begin. These sounds can be heard through stethoscope over brachial pulse point. (Systolic) The sounds continue for a time while the cuff is deflated slowly, eventually becoming to faint to hear. Last sound heard is (Diastolic) Measurement of Blood Pressure (2) Errors in Blood Pressure Measurement Erroneously high  Too narrow a cuff as much as 40 mmHg  Cuff applied too tightly or too loosely  Excessive pressure in cuff during measurement  Incomplete deflation of cuff between measurements Erroneously low  Too wide a cuff Blood Pressure Related to Shock Shock is defined precisely as the inadequate delivery of O2 and nutrients to the vital organs relative to their metabolic demand Shock is usually treated aggressively with fluids, blood products, or vasoactive drugs, or a combination of these  Cardiogenic shock  Hypovolemic shock  Septic shock  Anaphylaxis Syncope Pulse Oximetry Noninvasive monitoring technique performed at bedside Referred to as SpO2 Should reflect patients clinical condition Depending on level of care is dependent on monitoring  Allow sufficient response time before taking a reading  Never act on SpO2 readings alone  Clean & disinfect between patients Physical Examination Essential for evaluating patient’s problem and determining ongoing effects of therapy Consists of four steps: 1. Inspection (visually examining) 2. Palpation (touching) 3. Percussion (tapping) 4. Auscultation (listening with stethoscope) Examination of the Head and Neck Eyes  Evaluated as part of neurological exam  Pupillary reflexes tested by shining a light into the patients eyes  Pupils should be equal, round, reactive to light, an accommodation (PERRLA)  Pupils dilated (Mydriasis)  Pupils pinpoint (Miosis)  Ptosis (Drooping of upper lid) Examination of the Head and Neck Head  Abnormal signs help indicate respiratory problems  Nasal flaring: often seen in infants with respiratory distress—increased WOB  Cyanosis of oral mucosa (central cyanosis) indicates respiratory failure due to low oxygen levels  Pursed-lip breathing—seen in patients with COPD to prevent collapse of small airways Examination of the Head and Neck Neck  Inspection and palpation of the neck help determine the position of the trachea  May shift away from midline in certain thoracic disorders  Jugular venous distention (JVD) is seen in patients with CHF and cor pulmonale  Enlarged lymph nodes in neck may occur with infection or malignancy Lung Topography Must know how lungs are situated within chest in order to perform accurate physical assessment of respiratory system  Imaginary lines  Thoracic cage landmarks  Lung fissures  Tracheal bifurcation  Diaphragm  Lung borders Anterior Chest Wall Posterior Chest Wall Landmarks  Lung Fissures Anterior Chest Posterior Chest Examination of the Thorax and Lungs Inspection Chest should be inspected visually to assess:  The thoracic configuration  Expansion  The pattern and effort of breathing  Make every effort to respect the patient’s modesty Examination of the Thorax and Lungs Thoracic configuration  The anteroposterior (AP) diameter of the average adult thorax is less than the transverse diameter  The abnormal increase in AP diameter is called barrel chest  Associated with emphysema Examination of the Thorax and Lungs Thoracic configuration  Pectus carinatum  Pectus excavatum  Abnormal protrusion of  Depression of part or entire sternum sternum, which can produce a restrictive lung defect Examination of the Thorax and Lungs  Scoliosis  Kyphosis  Kyphoscoliosis  Spinal deformity in  Spinal deformity in  Combination of which the spine has which the spine has kyphosis and a lateral curvature an abnormal AP scoliosis, which may curvature produce a severe restrictive lung defect as a result of poor lung expansion Breathing Pattern and Effort Normal breathing Abnormal breathing Accessory muscles Retractions Diaphragm Breathing Patterns Breathing Patterns Examination of the Thorax and Lungs Thoracic expansion  Diaphragm is the primary muscle of breathing  Normal chest wall expands symmetrically and can be evaluated on the anterior and posterior chest  Diseases that affect the expansion of both lungs cause a bilateral reduction in chest expansion  Reduced expansion commonly is seen in neuromuscular disorders and COPD  Unilateral reduction in chest expansion occurs with respiratory diseases that reduce the expansion of one lung or a major part of one lung Chest Palpation Palpation is the art of touching the chest wall to evaluate underlying structure and function Vocal and tactile fremitus is with pneumonia and atelectasis (consolidation), lung masses Vocal and tactile fremitus is with emphysema, pneumothorax, and pleural effusion Percussion Over Lung Fields Performed systematically by consecutively testing comparable areas on both sides of the chest Percussion over bony structures and breasts should be avoided Having the patient raise his or her arms will help move scapulae laterally & minimize their interference with percussion on the back Evaluate percussion sounds for intensity (loudness) or pitch  Findings should be labeled as: “normal”,“increased,”or “decreased” resonance Chest Percussion Auscultation of the Lungs Auscultation Technique Auscultation of the Lungs Tracheal breath sounds  Heard directly over trachea; created by turbulent flow; loud with expiratory component equal to or slightly longer than inspiratory component Bronchovesicular breath sounds  Heard around upper part of sternum; between scapulae; moderate pitch and intensity Vesicular breath sounds  Heard over peripheral lung areas; very soft and low pitched Auscultation of the Lungs Normal breath sounds  Lung sounds are audible vibrations primarily generated by turbulent airflow in the larger airways  Sounds are altered as they travel through the lung periphery and chest wall  It preferentially passes low-frequency sounds  Clear; Vesicular/Bronchial Auscultation of the Lungs Adventitious (abnormal) lung sounds Two varieties: 1. Discontinuous  Intermittent crackling  Bubbling sounds of short duration  Referred to as “crackles” 2. Continuous  Referred to as “wheezes”  Heard over the upper airway is called “stridor”  Musical quality that are produced as air flows through constricted airways; May be heard with Asthma, Bronchitis, CHF, or FBO Auscultation of the Lungs 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  When sound transmission through lung or chest wall is decreased (COPD or asthma) Wheezes  Consistent with airway obstruction  Monophonic wheezing indicates one airway is affected  Polyphonic wheezing indicates many airways are involved Auscultation of the Lungs Stridor  Upper airway compromised  Chronic stridor—laryngomalacia  Acute stridor—croup  Inspiratory stridor—narrowing above glottis  Expiratory stridor—narrowing of lower trachea Coarse crackles  Airflow moves secretions or fluid in airways  Usually clears when patient coughs or upper airway is suctioned Fine crackles  Sudden opening of small airways in lung deep breathing  Heard with pulmonary fibrosis and atelectasis Pleural friction rub Voice Sounds Produced by same mechanism as vocal fremitus Have patient say “one” “two” “three” or “99” while examiner listens to chest wall with stethoscope comparing side to side Normal air-filled lung filters voice sounds which results in lower intensity and clarity Pathological abnormalities in lung alter transmission of sounds:  Increased  Egophony  Bronchophony  Decreased Cardiac Examination Chest wall overlying heart is known as precordium Inspected, palpated, and auscultated for abnormalities Right ventricular hypertrophy causes an abnormal pulsation that can be seen and felt near lower margin of sternum; consistent with cor pulmonale (COPD) Auscultation of Heart Sounds S1: created by closure of AV valves S2: created by closure of semilunar valves S3: abnormal in adults and caused by rapid filling of stiff left ventricle S4: caused by atrial “kick” of blood into noncompliant left ventricle When patient has both S3 and S4—gallop rhythm is present Abdominal Exam Abdomen inspected and palpated for distention tenderness An enlarged or tender abdomen can negatively influence breathing Abdominal compartment syndrome – when intraabdominal pressures >20 mm Hg. An enlarged liver (hepatomegaly) is consistent with cor pulmonale. An abnormal collection of fluid in the peritoneal cavity is known as ascites. Examination of Extremities Digital clubbing Cyanosis Pedal edema Capillary refill Peripheral skin temperature Skin turgor Examination of the Extremities Severe Clubbing Summary Physical examination provides reliable and important evidence regarding the patient’s clinical condition RTs must be skilled at PE to assess the patient’s condition and evaluate the effects of treatments The best evaluation usually comes from looking at multiple parameters from the Physical Exam