Cardiopulmonary Physical Therapy. Haneul Lee, DSc, PT

Transcription

1 Cardiopulmonary Physical Therapy Haneul Lee, DSc, PT

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3 1. History 2. Past medical history 3. Social history 4. Quality of life issues 5. Risk factors 6. Observation and inspection of skin color for possible signs of decreased cardiac output and low oxygen situation

4 History Presenting symptoms. Note onset, progression, nature of symptoms, insight into medica1 condition 1. Chest pain, pa1pitations, shortness of breath. 2. Fatigue: generalized feeling of tiredness, weakness. 3. Palpitations: awareness by patient of heart rhythm abnormalities 4. Dizziness, syncope (transient l0ss of consciousness) due to inadequate cerebra1 bl00d flow 5. Edema: retention of fluid in tissues; swelling, especially in dependent body parts/l0wer extremities; sudden weight gain

5 Past medical history Other diagnoses, surgeries Medications Social history Current living situation, family/social support Education level, employment Lifestyle, risk factor Quality-of-life issues Activities of dai1y living (ADLs); sleep Observation and inspection of skin color for possible signs of decreased cardiac output and 10w oxygen saturation Cyanosis: bluish color of the skin, nail beds, lips and tongue Pallor: washed out, absence of pink, rosy color Diaphoresis: excess sweating and cool, clammy skin

6 Positive Risk Factors

7 Rhythmical throbbing of arterial wall as a result of each heartbeat Influenced by force of contraction, volume and viscosity of blood, diameter and elasticity of vessels, emotions, exercise, blood temperature, and hormones. Determine pulses; palpate for 30 seconds with regular rhythm, 1-2 minutes with irregular rhythm

8 Apical pulse patient is supine, palpate at 5th interspace, midclavicular vertical line Radial palpate radial artery, radial wrist at base of thumb; most common monitoring site Carotid patient is lying down with head of bed elevated; palpate over carotid artery, on either side of anterior neck between sternocleidomastoid muscle and trachea Brachial palpate over brachial artery medial aspect of the antecubital fossa; used to monitor blood pressure Femoral palpate over femoral artery in inguinal region Popliteal palpate over popliteal artery, behind the knee with the knee flexed slightly Pedal palpate over dorsalis pedis artery, dorsal medial aspect of foot; used to monitor lower extremity circulation.

9 Irregular pulse variations in force and frequency ;may be due to arrhythmias, myocarditis Weak, thready pulse may be due to low stroke volume, cardiogenic shock Bounding, full pulse may be due to shortened ventricular systole and decreased peripheral pressure; aortic insufficiency

10 Normal adult HR is beats per minute(bpm); Pediatric: newborn average is 120 bpm; normal range bpm Tachycardia: >100 bpm. Exercise commonly results in tachycardia. Compensatory tachycardia can be seen with volume loss (surgery, dehydration) Bradycardia: <60 bpm

11 Normal : <120 mm Hg systolic; <80mm Hg diastolic Pediatric Infants <2 years : systolic; diastolic Children 3-5 years: systolic, 67-74diastolic Prehypertension: mm Hg systolic;80-89 mm Hg diastolic Hypertension Stage 1: mm Hg systolic; mm Hg diastolic Stage 2: mm Hg systolic; mm Hg diastolic Stage 3: >160 mm Hg systolic; >110 mmhg diastolic. Primary hypertension: no identifiable cause for elevated BP. Secondary hypertension: cause can be determined; may be related to arteriosclerosis and vascular disorders, renal disease, endocrine disorders, pregnancy, drug-related Majority of patients with hypertension are asymptomatic (2003 Joint National Committee on Prevention, Detection, Evaluation,and Treatment of High Blood Pressure Guidelines)

12 Hypotension A decrease in BP below normal; blood pressure is not adequate for normal perfusion/oxygenation of tissues. May be related to bed rest, drugs, arrhythmias, blood loss/shock, or myocardial infarction Orthostatic hypotension : sudden drop in BP that accompanies change in position Take BP in lying position (5 minutes). Repeat BP at 1 and 3 minutes after moving into sitting position, then standing position Drop in systolic BP of more than 20 mm Hg or standing BP less than 100 mm Hg systolic BP is significant and should be reported Common symptoms include lightheadedness, dizziness, loss of balance

13 Auscultation The process of listening for sounds within the body; stethoscope is placed directly on chest. Note intensity and quality of heart sounds Auscultation landmarks Aortic valve: 2nd right intercostal space at the sternal border Pulmonic valve: 2nd left intercostal space at the sternal border Erb s point : 3 rd left intercostal space at the sternal border Tricuspid valve: 4th left intercostal space at the sternal border. Mitral valve: 5th left intercostal space at the midclavical area

14 S1 (lub) 1 st heart sound - closure of the mitral and tricuspid valves at the onset of ventricular systole High frequency sound with lower pitch and longer duration than S2 S2 (dub) 2nd heart sound - closure of the aortic and pulmonic (semilunar) valves at the onset of ventricular diastole High frequency sound with higher pitch and shorter duration than S 1 S3 3rd heart sound - vibrations of the distended ventricle walls due to passive flow of blood from the atria during the rapid filling phase of diastole Normal in healthy young children; termed "physiologic 3rd heart sound Abnormal in adults S4 4th heart sound - pathological sound of vibration of the ventricular wall with ventricular filling and atrial contraction May be associated with hypertension, stenosis, hypertensive heart disease or myocardial infarction

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16 Murmurs Heart murmurs are vibrations of longer duration than the heart sounds and are often due to disruption of blood flow past a stenotic or regurgitant valve; the sounds are variably described as soft, blowing or swishing Normal heart sounds Normal Heart Sounds Auscultation Course Extra heart sounds Extra Heart Sounds (S3 and S4) Auscultation Course Murmurs Systolic MurmursAuscultation Course

17 : Determine rate, depth of breathing xjrg6bypjasrzciv18ktcpsxyj-oiox_g2qqndud4fm9pyty3zc Normal adult respiratory rate (RR) is breaths per minute. Pediatric: newborn RR is breaths per minute. Tachypnea: an increase in RR 22 breaths per minute Bradypnea: a decrease of RR 10 breaths per minute Hyperpnea: an increase in depth and rate of breathing

18 Dyspnea: shortness of breath (SOB) Dyspnea on exertion (DOE): brought on by exercise or activity. Orthopnea: inability to breathe when in a reclining position Paroxysmal nocturnal dyspnea (PND): sudden inability to breathe occurring during sleep Dyspnea scale National Physical Therapy Examination, O sullivan&siegelman, TherapyEd

19 Auscultation of the lungs : Assess respiratory sounds Normal breath sounds Assess for adventitious sounds Crackles (rales): rattling, bubbling sounds; may be due to secretions in the lungs. Wheezes: whistling sounds Lung sounds => Assess cough: productive or nonproductive

20 Use pulse oximetry, an electronic device that measures the degree of saturation of hemoglobin with oxygen (Sa02) Normal values are 95%-100% oxygen Provides an estimate of PaO2 (partial pressure of oxygen) based on the oxyhemoglobin desaturation curve. Hypoxemia: abnormally low amount of oxygen in the blood Saturation levels below 90% Hypoxia: low oxygenlevel inthe tissues Anoxia: complete lack of oxygen

21 Chest pain may be cardiac or non-cardiac in origin Ischemic cardiac pain (angina or myocardial infarction) Diffuse, retrosternal pain; or a sensation of tightness, achiness, in the chest; associated with dyspnea, sweating, indigestion, dizziness, syncope, anxiety Angina: sudden or gradual onset; occurs at rest or with activity; precipitated by physical or emotional factors, hot or cold temperatures; relieved by rest or nitroglycerin Myocardial infarction pain: sudden onset; pain lasts for more than 30 minutes; not relieved by medication Referred pain Cardiac pain can refer to shoulders, arms, neck, or jaw Pain referred to the back can occur from dissecting aortic aneurysm

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23 Examine for diaphoresis : excess sweating associatedwith decreased cardiac output Examine arterial pulses : decreased or absent pulses associated with peripheral vascular disease (PVD); examine bilaterally Lower extremity: position patient supine, check femoral, popliteal, dorsalis pedis, posterior tibial pulses Upper extremity: check radial, brachial, and carotid pulses

24 Examine skin temperature Temperature: decrease in superficial skin temperature is associated with poor arterial perfusion Examine for skin changes Clubbing: curvature of the finger nails with soft tissue enlargement at base of nail: associated with chronic oxygen deficiency Trophic changes: pale, shiny, dry skin, with loss of hair is associated with PVD Fibrosis: tissues are thick, firm, and unyielding Stemmer's sign: dorsal skin folds of the toes or fingers are resistant to lifting; indicative of fibrotic changes and lymphedema. Abnormal pigmentation, ulceration, dermatitis, gangrene is associated with PVD. Stemmer's sign

25 Examine for pain : intermittent claudication with pain, cramping, and fatigue occurring during exercise, and relieved by rest Related to arterial insufficiency: pain is typically in calf, may also be in thigh, hips, or buttocks. Patient may experience pain at rest with severe decrease in arterial blood supply; typically in forefoot, worse at night. Examine for edema Measure girth measurements using a tape, or volumetric measurements using a volumeter (irregular body parts) Pitting edema : depression is maintained when finger is pressed firmly Peripheral causes of edema include chronic venous insufficiency and lymphedema Bilateral edema is associated with congestive heart failure. volumeter National Physical Therapy Examination, O sullivan&siegelman, TherapyEd

26 Ankle Brachial Index (ABI) : the ratio of lower extremity (LE) pressure divided by upper extremity (UE) pressure ( LE/UE) BP cuff is inflated to occlude blood flow temporarily, then deflated. Examiner listens for return of flow Performed in UE at brachial artery; LE at posterior tibial and dorsalis pedis arteries ABI indices National Physical Therapy Examination, O sullivan&siegelman, TherapyEd

27 Examine color changes in skin : during elevation of foot followed by dependency (seated, hanging position) With insufficiency, pallor develops in elevated position; reactive hyperemia develops in dependent position Changes that take longer than 30 seconds are also indicative of arterial insufficiency.

28 Examine for intermittent claudication : exercise induced pain or cramping in the legs that is absent at rest. Usually calf pain, but may also occur in buttock, hip, thigh, or foot. Have the patient walk on level grade, 1 mile/ hour Note time of test. Use subjective ratings of pain scale to classify degree of claudication Examine for coldness, numbness, or pallor in the legs or feet; loss of hair over anterior tibial area. National Physical Therapy Examination, O sullivan&siegelman, TherapyEd

29 Palpate superficial lymph nodes Examine for edema Visual inspection: note swelling, decreased range of motion, loss of functional mobility Measure girth Examine skin Changes in skin texture, fibrotic tissue changes Presence of papules, leakage, wounds Changes in function (ADL, functional mobility, sleep ) Paresthesia may be present

30 1. National Physical Therapy Examination, O sullivan&siegelman, TherapyEd 2. Essentials of Cardiopulmonary PhysicalTherapy, 3 rd edition, Ellen Hillegass, Elsevier 3. Cardiovascular and pulmonary PhysicalTherapy Evidence to Practice, 5 th edition, Donna Frownfelter, Elizabeth Dean, Elsevier 4. Cardiopulmonary PhysicalTherapy Management and Case Studies, 2 nd edition, W.Darlence Reid, Frank Chung, Kylie Hill,SLACK Inc. 5. Steele, Joel Dorman Hygienic Physiology (NewYork, NY: A. S. Barnes & Company, 1888) 6. PTEXAM the complete study guide, Scott M Giles, Scorebuilders