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Cardiorespiratory assessment CResp Wk 10_ Tut 2_10_111.

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Presentation on theme: "Cardiorespiratory assessment CResp Wk 10_ Tut 2_10_111."— Presentation transcript:

1 Cardiorespiratory assessment CResp Wk 10_ Tut 2_10_111

2  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_112 Plan

3  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 CResp Wk 10_ Tut 2_10_113 Cardiorespiratory assessment

4  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 CResp Wk 10_ Tut 2_10_114 Cardiorespiratory assessment

5  Subjectively ◦ 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) CResp Wk 10_ Tut 2_10_115 How?

6  From patient or medical notes ◦ HPC  (PC) ◦ PMH ◦ SH  Including smoking, hobbies, accommodation ◦ FH ◦ Occupational history ◦ DH  Including allergies CResp Wk 10_ Tut 2_10_116 Data Base – in groups What are the components and what does it tell us?

7  Medical test results ◦ 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  current and any previous ◦ Blood test results  Hb (14-18 g/100ml Men, g/100ml Women)  ? Raised white cell count (N= 4-11x10 9 per litre)  Cardiac enzymes (Creatine Kinease, Troponin T)  Any reported ECG abnormalities CResp Wk 10_ Tut 2_10_117 From medical notes

8  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 (FEV 1 ) -forced vital capacity (FVC) -peak expiratory flow rate -Normal ratio FEV 1 /FVC around 80% (75-85%)  Obstructive pattern: ◦ ↓ FEV 1, ↔ FVC (ratio < 75%)  Restrictive pattern: ◦ ↓ FEV 1, ↓ FVC (ratio usually above 90%)  Calculate your values against normative data at  Normal values based on age, height and gender. CResp Wk 10_ Tut 2_10_118 Spirometry

9  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 CResp Wk 10_ Tut 2_10_119 From medical notes

10  Shortness of breath (SOB) - When? ◦ 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 CResp Wk 10_ Tut 2_10_1110 Subjective

11  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 CResp Wk 10_ Tut 2_10_1111 Subjective contd

12  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? CResp Wk 10_ Tut 2_10_1112 Subjective cont

13  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 CResp Wk 10_ Tut 2_10_1113 Sputum - Sputum - Either in subjective or objective

14  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 CResp Wk 10_ Tut 2_10_1114 Sputum

15  Exercise tolerance ◦ 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_1115 Subjective cont

16  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? Video CResp Wk 10_ Tut 2_10_1116

17  Covert observation of patient: ◦ 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 CResp Wk 10_ Tut 2_10_1117 On Examination

18  Observation of fingers/hands and toes/feet ◦ Cyanosis  Peripheral  +/- Central ◦ Clubbing  Respiratory disease (chronic)  Lung cancer  Liver disease  Congenital ◦ CO 2 flap  Observation of ankles/feet ◦ Oedema ◦ Perfusion  Observation of sputum CResp Wk 10_ Tut 2_10_1118 On Examination

19 CResp Wk 10_ Tut 2_10_1119 Finger clubbing

20  Auscultation ◦ 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  SpO 2 CResp Wk 10_ Tut 2_10_1120 On Examination

21  Temperature- ◦ Core  Usually measure in the ear (rectally in ITU)  Axilla about C less than core ◦ > C core temperature indicative of infection ◦ Peripheral  About 2 0 C less than core  Any more indicates CVS problems in unwell patient  HR  BP  Peripheral oedema ◦ Indicates right sided heart failure  Jugular Venous Pressure ◦ Indicates right sided heart failure ◦ Normal JVP < 3-4 cm above sternal angle with the patient sitting up 45 degrees CResp Wk 10_ Tut 2_10_1121 CVS

22 CResp Wk 10_ Tut 2_10_1122 Raised JVP

23  Exercise tests give an indication of progress  Borg scale ◦ Perceived Exertion  corresponds to 60% of VO 2 max.  15 corresponds to 75% of VO 2 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. CResp Wk 10_ Tut 2_10_1123 Other outcome measures

24  Visual Analogue Scale No breathlessness Greatest Breathlessness CResp Wk 10_ Tut 2_10_11

25  Intubated and ventilated patient  Paediatrics and neonates  Always remembering clinical features of hypoxaemia and hypercapnia CResp Wk 10_ Tut 2_10_1125 Variations on a theme

26  Cyanosis  Tachypnoea  Tachycardia → arrhythmias/ bradycardia  Peripheral vasoconstriction  Respiratory muscle weakness  Restlessness → confusion → coma CResp Wk 10_ Tut 2_10_1126 Clinical Features of Hypoxaemia

27  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_1127 Clinical Features of Hypercapnia

28  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_1128 Then …

29  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_1129 An example of one problem for a patient with newly diagnosed Bronchiectasis

30  Should be S.M.A.R.T ◦ Simple ◦ Measurable ◦ Achievable ◦ Realistic ◦ Time scaled CResp Wk 10_ Tut 2_10_1130 Goals

31  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_1131 In conclusion

32  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_1132 Learning outcomes

33  Bourke, S. J. (2003). Lecture notes on respiratory medicine. (6 th 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. (4 th ed.). Edinburgh: Churchill Livingstone  Wilkins, R. L., Sheldon R. L. & Krider, S. J. (2005). Clinical assessment in respiratory care. (5 th ed.). Missouri: Elsevier Mosby. CResp Wk 10_ Tut 2_10_11 33 Bibliography


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