Assessing The Patient

Transcription

1 Assessing The Patient Robert Harwood, MHA, RRT-NPS Objectives At the end of this presentation the student should be able to: Assess general appearance of a patient s head, neck and face, including venous distention, edema, accessory muscle activity, chest wall movement, diaphoresis, clubbing, cyanosis and breathing pattern Assess the patient s airway, including macroglassia and neck range of motion Collect and evaluate clinical information concerning cough, sputum, and the character and amount of sputum Evaluate a patient s condition using Apgar score, gestational age, and transillumination of the chest 1

2 General Appearance General appearance characteristics: Facial expression- pain Body position- tripod (COPD) Distress, diaphoresis- short of breath Look of anxiousness- hypoxia Malnutrition, emaciated, generally ill (cachexia)- COPD Questions with these characteristics, you would want to treat and stabilize the patient Examination of Head and Neck Respiratory disease signs: Nasal flaring-increased flow rate Cyanosis: Central vs. Peripheral Central Need: requires oxygen Location: lips, nose, ears, neck region, tongue Darker pigmentation more difficult to see Look at palm of hands, oral cavity, tongue Peripheral or acrocyanosis Poor circulation to extremities- cool Pursed-lip breathing 2

3 Sample Question A patient is receiving oxygen by nasal cannula at 3 L/minute. Upon inspection you notice the patient to have central cyanosis. This would indicate the presence of cyanosis to be: a. In the feet and ankles b. In the neck region and lips c. In the hands, fingers and wrists d. From the knees to the ankles Sample Question Answers b. Correct answer-neck region, lips, tongue, ears 3

4 Examination of Head and Neck EYES Normal- pupils equal, round, reactive to light PERRLA Dilated and fixed pupils- brain death - Miadriasis Pinpoint pupils - Miosis (opiates) Double vision - Diplopia Neuromuscular disease, e.g. Myasthenia gravis Examination of Head and Neck NECK Normal tracheal position: midline Assess: palpation of suprasternal notch Abnormal tracheal position Shift toward affected lung - pull Severe Atelectasis Opposite Lung Shift away from affected lung - push Pneumothorax, pleural effusion 4

5 Examination of Head and Neck Jugular Venous Pressure Level of column of blood in jugular vein reflects: Volume Pressure Right Heart Abnormal conditions Right sided heart failure from: Chronic hypoxemia-copd Secondary to left-sided heart failure-chf Head elevated 45 degrees-distention 3-4 cm above sternal angle to angle of the jaw is abnormal Sample Question A male COPD patient is being assessed in the ICU following admission for acute exacerbation of his condition. The patient is lying in bed with the head of the bed at a 45 angle. Upon inspection, it is noticed that the jugular vein is distended to the jaw line. This finding would indicate the presence of which of the following? a. Anemia b. Polycythemia c. Kidney failure d. Right-sided heart failure 5

6 Sample Question Answer d. Correct answer. Right sided heart failure can occur from chronic hypoxemia or 2 nd to CHF. Examination of Thorax Inspection to determine Normal thorax: Anterior Posterior (AP) diameter < transverse diameter Abnormal AP diameter = barrel chest Common in COPD (emphysema), CF Ribs loose normal 45º angle = horizontal Other Abnormal Thorax Inspection Pectus carinatum - chest characterized by a protrusion of the sternum and ribs Pectus excavatum - a caved-in or sunken appearance of the chest Kyphosis - over-curvature of the thoracic vertebrae (upper back) Scoliosis - person's spine is curved from side to side Kyphoscoliosis - combination of kyphosis and scoliosis Flail chest - detachment of the rib cage from the chest wall causing the flail segment to move in the opposite direction as the rest of the chest 2-2 rule: two ribs broken in 2 adjacent places 6

7 Accessory Muscle Activity Indicates need for greater air flow Patient has an increased work of breathing Associated with diaphoresis, increased heart rate, desaturation Cardiopulmonary disease increased use of accessory muscles of inspiration and expiration Retractions- increased airway resistance and decreased lung compliance Substernal retractions Intercostal retractions Sample Question Upon inspection of the head, neck and thorax, you notice the patient has respiratory distress and increased work of breathing. Which of the following would be present to indicate this finding? I. Nasal flaring II. Pitting edema III. Jugular vein distention IV. Intercostal retractions a. I, II b. I, IV c. I, II, III d. I, II, III, IV 7

8 Sample Question Answers b. Correct. Nasal flaring and intercostal retractions are associated with increased work of breathing Breathing Patterns Breathing Pattern Cause Description Apnea Respiratory or cardiac arrest Cessation of breathing Biot s High ICP Irregularity with breathing/long apnea spells Kussmaul s Metabolic acidosis Fast and deep (>20 bpm) Cheyne-Stoke s CHF, CNS disorders Increase and decrease breathing rate and volume, periods of apnea Paradoxical Trauma, paralysis of diaphragm Affected area moves in with inspiration opposite of the rest of the lung. Tachypnea Anxiety, hypoxemia Fast, shallow Bradypnea Sedation, hypoxemia Abnormally slow breathing (<12 bpm) Hyperpnea Fever, pain Deep breathing Hypopnea Sedation Shallow and slow breathing 8

9 Sample Question A patient has returned from a procedure requiring administration of a sedative. After evaluating the patient, the respiratory therapist charts that the patient has hypopnea. This type of breathing pattern would be associated with which of the following? a. Fast and shallow b. Irregular breathing with periods of apnea c. Shallow and slow breathing d. Deep breathing with snoring Sample Question Answer c. Correct. Hypopnea is shallow and slow breathing. 9

10 Sample Question A 23-year-old male is in the ED for contusions sustained from a fall while pruning a tree. He is receiving 40% oxygen by airentrainment mask. Upon inspection, it is noticed that the patient s right chest sinks in during inspiration while the rest of the chest rises. This type of breathing pattern would be referred to as which of the following? a. Kussmaul s b. Paradoxical c. Cheyne-Stoke s d. Pneumonic Sample Question Answers b. Correct- affected area moves in with inspiration opposite to the rest of the lung a. Not correct- fast, deep breathing c. Incorrect- Increased and decreased breathing rate and volume, periods of apnea d. Incorrect- no such breathing pattern 10

11 Inspection of Extremities Digital Clubbing Manifestation of chronic cardiopulmonary disease seen in Cystic Fibrosis, bronchiectasis, COPD Enlargement of the phalanges of the fingers and toes Angle of the nail advances past 180 degrees Edema Soft-tissue swelling. Pitting edema is present. Localized or generalized (anasarca) Associated with kidney, liver, cardiac, pulmonary disease, and venous or lymphatic drainage obstruction Unilateral peripheral edema- may be from venous obstruction Inspection of Extremities Bilateral peripheral (dependent) edema Cause: Cor pulmonale - right heart failure Progression: feet and ankles = abdominal organs = hepatomegaly = jugular vein distension Pitting edema scale Normal: Pitting returns rapidly Severe: >2 minutes 1+ trace (around ankles) to 4+ severe (well above knee) 11

12 Inspection of Extremities Capillary Refill commonly performed before obtaining an arterial blood gas Assessment to determine blood flow to extremities Blanch extremity Refill time < 3 seconds Refill time > 3 seconds Normal Reduced cardiac output, dehydration Inspection of Airway Macroglossia- unusual enlargement (hypertrophy) of the tongue Small oral airway- greater potential for obstruction Problems with swallowing and sleeping (obstructive sleep apnea) Neck Range of Motion Active- patient able to touch chin to chest Passive- therapist moves the patient s head Flexibility may be assessed for potential problems with intubation 12

13 Inspection of Airway - Mallampati Scoring -Difficult Intubation Very difficultonly hard palate visible No difficulty Grade IV Grade I Moderate difficulty Soft palate and partial uvula visible Grade III Grade II No difficulty Cough and Sputum Inspection Cough description- Effective, productive-mucus producing Inadequate-no mucus, weak, clearing throat Vital capacity less than normal (< ml/kg of IBW) Dry-could be effective or ineffective but no mucus production Directed cough-full, deep cough, against closed glottis Huff cough-slow, deep breath, open glottis, quick exhalation Recurrent (children)-allergies, asthma Dry-infection (viral) Dry (initially) then becomes productive-smoking, emphysema Chronic and very productive-bronchiectasis Stridor-croup, epiglottitis Wheezy-asthma Paroxysmal (often at night) asthma, left heart failure Barking-croup 13

14 Appearance and Cause-Sputum Emphysema Infection, pneumonia Infection, pneumonia, CF Bronchiectasis Smoke inhalation or cigarette smoker Mucoid Purulent Mucopurulent Foul odor and layered Black or Brown Blood Streaked, hemoptysis Frothy white or pink Lung cancer Tuberculosis Trauma Pulmonary edema Cough and Sputum Inspection HEMOPTYSIS HEMATAMESIS BRIGHT RED BLOOD LUNG DARK, GROUND COFFEE STOMACH 14

15 Cough and Sputum Inspection ACUTE < 3 weeks Common Cold SUBACUTE 3-8 weeks Respiratory Tract Infection CHRONIC > 8 WEEKS Asthma GERD TYPES OF COUGH Inspection of Newborn-APGAR Score SIGN 0 SCORE 1 SCORE 2 SCORE A APPEARANCE- COLOR PALE, BLUE ACROCYANOSIS PINK P PULSE-HEART- RATE G GRIMACE- REFLEX A ACTIVITY- MUSCLE TONE ABSENT <100 >100 NO RESPONSE GRIMACE COUGH, SNEEZE FLACCID SOME FLEXION WELL FLEXED R RESPIRATIONS- EFFORT ABSENT WEAK, IRREGULAR GOOD CRYING 15

16 APGAR Score Purpose Determine quickly whether a newborn needs immediate medical care Continue scoring until a 7 score is obtained 1 and 5 minutes following birth Score 7-10 Normal Score 4-6 Fairly Low Score < 3 Critically Low Sample Question A 37-week gestational age newborn has just been born and the following APGAR score has been obtained: Appearance/color: Acrocyanosis Pulse: 147/min Grimace reflex: Good cough Activity-Muscle tone: Some Flexion Respirations: Weak, irregular Based on this finding you would recommend an APGAR score of: a. 9 b. 8 c. 7 d. 5 16

17 Sample Question Answer c. Correct: Score of 7 Appearance/color: Acrocyanosis 1 point Pulse: 147/min 2 points Grimace reflex: Good cough 2 points Activity-Muscle tone: Some Flexion 1 point Respirations: Weak, irregular 1 point Gestational Age Assessment Maternal Dates Dubowitz Scoring GESTATIONAL AGE ASSESSMENT Fetal Ultrasound Ballard Scoring 17

18 Inspection of Newborn Chest Transillumination of Chest Normal Findings: Halo appearance on chest Abnormal Findings: Area under light lights up from air or fluid References Clinical Assessment in Respiratory Care, Sixth Edition, Robert L. Wilkins, James R. Dexter, Albert J. Heuer, (2009), The Mosby/Elsevier Company, St. Louis, MO. Egan s Fundamentals of Respiratory Care, Ninth Edition, Robert L. Wilkins, James K. Stoller, Robert M. Kacmarek, (2009), Mosby/Elsevier Company, St. Louis, MO Respiratory Care Principles and Practice, Second Edition, Dean R. Hess, Neil R. MacIntyre, Shelley C. Mishoe, William F. Galvin, Alexander B. Adams, (2011), Jones and Bartlett Learning, Sudbury, MA The Essentials of Respiratory Care. Robert M. Kacmarek, Steven Dimas, Craig W. Mack (2005). Fourth Edition. Mosby/Elsevier, St. Louis, MO Perinatal and Pediatric Respiratory Care. Brian K. Walsh, Michael P Czervinske, Robert M. DiBlasi (2010). Saunders Elsevier, St. Louis, MO 18