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Cardiorespiratory assessment

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1 Cardiorespiratory assessment
CResp Wk 10_ Tut 2_10_11

2 Plan Overview of respiratory and cardiovascular assessment to give you a framework on which to base your assessment process when out on clinical placement for the self ventilating adult patient Handout on StudyNet Please read around in the textbooks CResp Wk 10_ Tut 2_10_11

3 Cardiorespiratory assessment
From lecture: Why do we assess patients? To identify physiotherapy problems for management To ascertain the patient’s perceptions of their problems To identify potential indications for treatment techniques/management strategies To identify potential contra-indications for treatment techniques/management strategies - Identify physiotherapy problems for management - Ascertain patient’s perceptions of their problems - Identify potential indications for treatment techniques/management strategies - Identify potential contra-indications for treatment techniques/management strategies CResp Wk 10_ Tut 2_10_11

4 Cardiorespiratory assessment
From lecture: When do we assess patients? First contact Ongoing throughout treatment Before and after every patient contact Maybe use more formal outcome measures at certain times during management Before discharge First contact Ongoing throughout treatment Before and after every patient contact Maybe use more formal outcome measures at certain times during management Before discharge CResp Wk 10_ Tut 2_10_11

5 How? Subjectively Objectively
Everything the patient/other staff tell us about the patient’s condition Objectively Everything we see/identify from charts/measure (remember: points from other modules about writing up etc) Everything the patient/other staff tell us about the patient’s condition - Everything we see/identify from charts/measure CResp Wk 10_ Tut 2_10_11

6 From patient or medical notes
Data Base – in groups What are the components and what does it tell us? From patient or medical notes HPC (PC) PMH SH Including smoking, hobbies, accommodation FH Occupational history DH Including allergies HPC : ongoing issues (Fever, Dyspnoea- relate to fnc, Chest pain, Cough/sputum, Exs tolerance, Patterns/24hr Function, Weight loss, Oedema,) & Norms, PC: Onset sudden/insidious, Length time, Severity, Nature, Aggs/Easing, Pattern PMH: prev episodes or other cardiovascresp diseases or neurological, musculoskeletal problems &/or Ops CResp Wk 10_ Tut 2_10_11

7 From medical notes Medical test results Any reported ECG abnormalities
Sputum MC+S CXR current and any previous Pulmonary/Lung Function Tests Peak Expiratory Flow Rate (litres per minute) Spirogram - expiration Flow volume loops –expiration into inspiration ABGs Blood test results Hb (14-18 g/100ml Men, g/100ml Women) ? Raised white cell count (N= 4-11x109 per litre) Cardiac enzymes (Creatine Kinease, Troponin T) Any reported ECG abnormalities Microbial culture and sensitivity Spirometery = lung volumes, forced expiratory rates. Flow loop = same as spirometry followed into Insp. Hb usually transfuse <9/10 CK realised by damaged skeletal muscle, Trop. T more specific to cardiac CResp Wk 10_ Tut 2_10_11

8 Spirometry The graph produced from a max. forced expiration following
a full inspiration is called a forced expiratory spirogram. Spirometer Measures: -forced expiratory vol. in 1 second (FEV1) -forced vital capacity (FVC) -peak expiratory flow rate -Normal ratio FEV1/FVC around 80% (75-85%) Obstructive pattern: ↓ FEV1, ↔ FVC (ratio < 75%) Restrictive pattern: ↓ FEV1, ↓ FVC (ratio usually above 90%) Calculate your values against normative data at Normal values based on age, height and gender. Should always compare to predicted values i.e. taller men fit man very different to small elderly women and same ratio drop may be v. significant >15% below predicted values is significant VC=Vital Capacity FRC= Functional Residual Reserve TLC = Total Lung Capacity TV = Tidal Vol. RV = Residual Volume CResp Wk 10_ Tut 2_10_11

9 From medical notes Current drugs
?? Oxygen: route/duration and concentration Bronchodilators: timings of doses to fit in with your treatment Analgesia: timing to fit in with your treatment Antibiotics Inhaled steroids Nebulisers Nebulised: Steroids, Antibiotics, saline CResp Wk 10_ Tut 2_10_11

10 Subjective Shortness of breath (SOB) - When? ? snoring
On Exertion (SOBOE) At Rest (SOBAR), or at Night Sleep with how many pillows? Orthopnoea Unable to lie flat without becoming dyspnoeic Supposedly classic of pulmonary oedema but present in many respiratory diseases Paroxysmal nocturnal dyspnoea (PND) Sudden waking at night because of breathlessness. Supposedly classic of pulmonary oedema but present in many respiratory diseases, especially morning dips of asthma ? Wake up coughing ? snoring - Significant breathlessness indicated by rushed sentences or pausing between getting undressed. - Orthopnoea: classically many resp. disease as increased pressure on diaphragm from abdo OR: can be Cardiac as blood pools in lungs, cos of left ventricle insufficiency - PND: SOBAR or nocturnal bronchospasm - Snoring ?? Sleep Apnoea - symptom of tracheal insufficiency & airways collapsing followed by sudden arousal from cortex stimulated by drop sats upto 75%. Can be Obstructive (obesity), Restrictive (AS) as Accessory MMs inhibited or Central (neurological) CResp Wk 10_ Tut 2_10_11

11 Subjective contd Cough When Exacerbating factors
Type; dry or productive, +/- painful, ?pattern Productive of phlegm/sputum? Colour: consistency, smell, taste Volume: teaspoon, egg cup, yoghurt pot Ease of expectoration Pain- Muscular trauma, rib #s. Persistent cough May also lead to hernia & stress incontinence Dry persistent - ? institial damage Loud Bark - ? Laryngeal/Tracheal disease Chronic Productive – Chronic Bronchitis/Bronchiectasis Nocturnal –?? Asthma sign in children/young. In older pts- ?? Cardiac failure /overload Cough stimulated by Tracheal Rub prox to sternum or suctioning (Yanker & NP) CResp Wk 10_ Tut 2_10_11

12 Subjective cont Chest Pain: Location Type Aggravating factors
How long does it last when aggravated? Easing/relieving factors? Aiming to ascertain Is it pleuritic in nature Localised/sharp, stabbing- worse on Inspiration Is it cardiac in nature? (dull, central, gripping +/- radiates to jaw & arm) Is pain relief adequate? Is there a musculoskeletal component? As lung parenchyma have no pain fibres, Pain generally: Musculoskeletal –Bony/Joints/Nerves Pleuritic or could indicate PE, Tumors, MI/Angina CResp Wk 10_ Tut 2_10_11

13 Sputum - Either in subjective or objective
Normal = mucoid White/clear Smokers White with variable amounts of grey/black flecks/brownish Infected = purulent Yellow – some form of infection Green (apple green classic of haemophilus influenza) Dark green/brown - pseudomonas Rusty brown – classic of pneumoccocal pneumonia Red currant jelly - klebsiella Consistency Very thick ? Need humidification/increase in fluid intake Very loose and frothy Maybe pulmonary oedema especially if white tinged with pink Bronchial casts – asthma, occasionally bronchiectasis Normal to produce 100 ml tracheal-bronchial secretions/day CResp Wk 10_ Tut 2_10_11

14 Sputum Blood stained = haemoptysis
Occasional flecks during acute infection – monitor Excess over longer time period indicative of cancer Other causes: Pulmonary embolism/infarct TB Ruptured blood vessel in bronchial mucosa (reasonably common with CF/bronchiectasis) Old/new (dark/bright red)/frank haemoptysis Smell! Taste (to the patient!) Strength of cough ? Effective (esp. relevant post-op i.e pain inhibition) ? Vocal cord paralysis/glottis closure Frank haemoptysis? related to Tracheal or Bronchial trauma i.e suctioning or PE Possibly life threatening involving rupture of Bronchial Artery. Isolated incidence ? sign of Bronchial CA Common with Chronic Lung Dis. Smell = Infection, Offensive = Anaerobic Infec CResp Wk 10_ Tut 2_10_11

15 Subjective cont Exercise tolerance Depending on the circumstances
How far without getting SOB ? Hills/inclines ? Stairs How long do you need to rest for? Anything they can’t do because of their breathing Depending on the circumstances What the patient would like to be able to achieve as a result of physiotherapy intervention (can give good info re. goals/motivating factors) CResp Wk 10_ Tut 2_10_11

16 Video Using your handouts from StudyNet re Assessment when watching the video Start to think about the order of questioning The importance of listening to the answers What is the usefulness of the answers – what do they mean? CResp Wk 10_ Tut 2_10_11

17 On Examination Covert observation of patient: Observation of thorax:
Appearance, Posture, Alertness, Respiratory rate/pattern (over 1min), Speech Observation of thorax: Tracheal position (mid line or shifted?) Chest shape Thoracic expansion Degree Where – upper/lower/ is expansion bilateral and equal Use of accessory muscles/fixing upper limbs General ease of ventilation/WOB ? Using pursed lip breathing I:E ratio, ? Prolonged expiratory phase Audible wheeze/harshness of respiration/stridor - Posture suggest: Fatigue, Pain, Altered Conscious/Incohernet (Hypoxia), Restless, Bracing arms - Obese: ?? Diaphragmatic fnc, Cachectic: ?? Nutrition/weakness Unkept because of Limitations by SOB & self care or  esteem 2° Dis Chronic lung Dis = Barrel shape Hyperinflated, Rigid chest,  AP diameter Pigeon chest (pectus carinitum) Funnel chest (pectus excavatum), Kyphosis, Kyphoscolisis Pursed Lip Breathing: Severe Airways Dis. provides own PEEP and stops airways collapsing. Paradoxical breathing: Inward Abdo during Insp 2° fatigue Apnoea: Absence breath Normal I:E is 1: Prolonged Expiration: Obstructive Lung Dis. & closure small airways > 15 secs Cheyne-Stokes: Irregular breathing (shallow or apnoeic breathing)  WOB = Use: Sternomastoid & Scaleni MMs, Recession soft tissue (Supraclavicular Suprasternal, Intercostal 2°  -ve pressure in chest Stridor = Monophnoic “strangled” Wheeze audible at mouth = Laryngeal or Tracheal narrowing / Upper Airways Obs CResp Wk 10_ Tut 2_10_11

18 On Examination Observation of fingers/hands and toes/feet
Cyanosis Peripheral +/- Central Clubbing Respiratory disease (chronic) Lung cancer Liver disease Congenital CO2 flap Observation of ankles/feet Oedema Perfusion Observation of sputum - Periph. Cyanosis = blue tinge 2°  stagnation of blood (gives of O2) from  Circ,  HB Saturation - Central Cyanosis =  Gas exchange & Hypoxaemia. Pulmonary Clubbing = Fibrosing Alveolititis, CF Recent onset ?? 1st sign Bronchial CA C02 retention Flap = Periph. Vasodilation from Hypercapnia &  Warmth/Sweat Oedema many reason but RESP PTs =  Kidney Perfusion from Chronic Hypoxaemia & Heart failure CResp Wk 10_ Tut 2_10_11

19 Finger clubbing Loss of angle between nail bed and nail
Finger pad enlarges Nail becomes spongy CResp Wk 10_ Tut 2_10_11

20 On Examination Auscultation Vocal resonance & whispering pectoriloquy
Presence of breath sounds Decreased/absent/bronchial Presence of added sounds Crackles/wheeze Inspiratory/expiratory Pleural rub Vocal resonance & whispering pectoriloquy Increased/decreased/normal Percussion note? Resonant/hyper-resonant/dull CXR You assess as well as reading any reports if available, +/- compare to previous films SpO2 Crackles: air forced through narrowed airway – Oedema, Inflammation or Secs (Late Insp = Atelectasis, Early = Sputum retention Wheezes; Vibration of airway wall as air rushes through ( Exp = Brochospasm, Insp/Exp = Obstruction)  Voice = Consolidation, Atelectasis,  = Atelectasis with blockage, Pneumo, Pleural Effusion PN (Middle finger-Distal IP struck) = Chest wall vibrating over underlying tissues. Resonant: Normal Hyperesonanace: Excess air (Pneumo) Stony Dull: Effusion/Fluid Dull : Atelectasis Systematic X-ray interpretation: Orientation, View, Exposure, Inflation, Bones, Medistenum/trachea, Lung fields CResp Wk 10_ Tut 2_10_11

21 CVS Temperature- HR BP Peripheral oedema Jugular Venous Pressure Core
Usually measure in the ear (rectally in ITU) Axilla about C less than core > C core temperature indicative of infection Peripheral About 2 0C less than core Any more indicates CVS problems in unwell patient HR BP Peripheral oedema Indicates right sided heart failure Jugular Venous Pressure Normal JVP < 3-4 cm above sternal angle with the patient sitting up 45 degrees CResp Wk 10_ Tut 2_10_11

22 Raised JVP CResp Wk 10_ Tut 2_10_11

23 Other outcome measures
Exercise tests give an indication of progress Borg scale Perceived Exertion 6-20. 12-13 corresponds to 60% of VO2 max. 15 corresponds to 75% of VO2 max Be consistent MRC Dyspnoea Scale – for breathlessness Visual Analogue Scale (VAS) for breathlessness (specify which is used 0-10 or 0-5) 6MWT and modified shuttle walk test Will do in Semester B – maybe mentioned in cardiac rehabilitation next week. 6MWT- walk as fast as reasonably possible along flat corridor, rest allowed but included in 6mins. Measure distance, Sats & HR = Endurance. 15% change is clinically significant. Need 3-4 practises Shuttle or “Bleep” test = 10 m oval coned circuit, incremental  speed dictated by tape. ½hr between practice & test MRC – 1. Not troubled by breathlessness except on strenuous exercise 2. Short of breath when hurrying or walking up a slight hill 3. Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace 4. Stops for breath after about 100 m or after a few minutes on the level 5. Too breathless to leave the house, or breathless when dressing or undressing CResp Wk 10_ Tut 2_10_11

24 Shuttle Test & VAS 1 10 Visual Analogue Scale
No breathlessness Greatest Breathlessness CResp Wk 10_ Tut 2_10_11

25 Variations on a theme Intubated and ventilated patient
Paediatrics and neonates Always remembering clinical features of hypoxaemia and hypercapnia CResp Wk 10_ Tut 2_10_11

26 Clinical Features of Hypoxaemia
Cyanosis Tachypnoea Tachycardia → arrhythmias/ bradycardia Peripheral vasoconstriction Respiratory muscle weakness Restlessness → confusion → coma CResp Wk 10_ Tut 2_10_11

27 Clinical Features of Hypercapnia
Flapping tremor of hands Tachypnoea Tachycardia → bradycardia Peripheral vasodilatation leading to warm hands and headache Respiratory muscle weakness Drowsiness → hallucinations → coma Sweating CResp Wk 10_ Tut 2_10_11

28 Then … You should be able to:
Identify the patient’s physiotherapy problem list Write a treatment plan related to the problem list Identify short and long term goals N.B. the degree of the patient’s contribution will vary CResp Wk 10_ Tut 2_10_11

29 Physiotherapy problem Treatment plan (would need more details)
An example of one problem for a patient with newly diagnosed Bronchiectasis Physiotherapy problem Difficulty expectorating retained pulmonary secretions Treatment plan (would need more details) Teach the patient ACBT Positioning to facilitate drainage of secretions Added humidification (Manual techniques) Goals Short term – to increase the patient’s ability to expectorate pulmonary secretions during physiotherapy treatment Long term - to enable the patient to be independent in the management of their pulmonary secretions in a month CResp Wk 10_ Tut 2_10_11

30 Goals Should be S.M.A.R.T Simple Measurable Achievable Realistic
Time scaled CResp Wk 10_ Tut 2_10_11

31 In conclusion A framework for all respiratory assessments (always includes CVS) Detail will vary according to patient group Practical this week Some cardiovascular and respiratory tools of assessment in practice CResp Wk 10_ Tut 2_10_11

32 Learning outcomes identify the importance of the physiotherapist assessing a patient at the beginning during and at the end of every treatment identify the differences and links between the subjective and objective assessment describe the various components of a cardio respiratory assessment discuss the implications of the results of the assessment on the composition of a physiotherapy problem list discuss the implications of the results of the assessment on the composition of a physiotherapy treatment plan relate the importance of the cardiovascular system assessment to the assessment of the respiratory system identify the components of a cardiovascular assessment begin to describe the implications of the results of a cardiovascular assessment CResp Wk 10_ Tut 2_10_11

33 Bibliography Bourke, S. J. (2003). Lecture notes on respiratory medicine. (6th ed.). Padstow UK: Blackwell Publishing. Harden, B. (Ed). (2004). Emergency physiotherapy. Edinburgh: Churchill Livingstone. Hough, A. (2001). Physiotherapy in respiratory care. (3rd ed.). Cheltenham: Nelson Thornes. Pryor, J. A. & Prasad, S. A. (Eds). (2008). Physiotherapy for respiratory and cardiac problems - adults and paediatrics. (4th ed.). Edinburgh: Churchill Livingstone Wilkins, R. L., Sheldon R. L. & Krider, S. J. (2005). Clinical assessment in respiratory care. (5th ed.). Missouri: Elsevier Mosby. CResp Wk 10_ Tut 2_10_11

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