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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

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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

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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

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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)

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From patient or medical notes◦ HPC

(PC)

◦ PMH◦ SH

Including smoking, hobbies, accommodation

◦ FH◦ Occupational history◦ DH

Including allergies

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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, 11.5-15.5g/100ml Women) ? Raised white cell count (N= 4-11x109 per litre) Cardiac enzymes (Creatine Kinease, Troponin T)

Any reported ECG abnormalities

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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 http://www.patient.co.uk/showdoc/40002357/

Normal values based on age, height and gender.

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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

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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

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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

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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?

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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

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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

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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)

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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?

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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

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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

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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 SpO2

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Temperature- ◦ Core

Usually measure in the ear (rectally in ITU) Axilla about 0.5-1 0C less than core

◦ > 37.5 0C 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

◦ Indicates right sided heart failure◦ Normal JVP < 3-4 cm above sternal angle with the patient sitting

up 45 degrees

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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.

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Visual Analogue Scale

No breathlessness Greatest Breathlessness

1 10

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Intubated and ventilated patient Paediatrics and neonates

Always remembering clinical features of hypoxaemia and hypercapnia

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Cyanosis Tachypnoea Tachycardia → arrhythmias/ bradycardia Peripheral vasoconstriction Respiratory muscle weakness Restlessness → confusion → coma

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Flapping tremor of hands Tachypnoea Tachycardia → bradycardia Peripheral vasodilatation leading to warm

hands and headache Respiratory muscle weakness Drowsiness → hallucinations → coma Sweating

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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

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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

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Should be S.M.A.R.T ◦ Simple◦ Measurable◦ Achievable◦ Realistic◦ Time scaled

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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

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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

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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.

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