Cardiorespiratory assessment CResp Wk 10_ Tut 2_10_11
Plan CResp Wk 10_ Tut 2_10_11 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
Cardiorespiratory assessment CResp Wk 10_ Tut 2_10_11 • 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
Cardiorespiratory assessment CResp Wk 10_ Tut 2_10_11 • 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
How? CResp Wk 10_ Tut 2_10_11 • 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)
Data Base – in groups What are the components and what does it tell us? CResp Wk 10_ Tut 2_10_11 • From patient or medical notes • HPC • (PC) • PMH • SH • Including smoking, hobbies, accommodation • FH • Occupational history • DH • Including allergies
From medical notes CResp Wk 10_ Tut 2_10_11 • 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
Spirometry CResp Wk 10_ Tut 2_10_11 • 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.
From medical notes CResp Wk 10_ Tut 2_10_11 • 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
Subjective CResp Wk 10_ Tut 2_10_11 • 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
Subjective contd CResp Wk 10_ Tut 2_10_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
Subjective cont CResp Wk 10_ Tut 2_10_11 • 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?
Sputum - Either in subjective or objective CResp Wk 10_ Tut 2_10_11 • 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
Sputum CResp Wk 10_ Tut 2_10_11 • 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
Subjective cont CResp Wk 10_ Tut 2_10_11 • 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)
Video CResp Wk 10_ Tut 2_10_11 • 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?
On Examination CResp Wk 10_ Tut 2_10_11 • 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
On Examination CResp Wk 10_ Tut 2_10_11 • 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
Finger clubbing CResp Wk 10_ Tut 2_10_11
On Examination CResp Wk 10_ Tut 2_10_11 • 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
CVS CResp Wk 10_ Tut 2_10_11 • 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
Raised JVP CResp Wk 10_ Tut 2_10_11
Other outcome measures CResp Wk 10_ Tut 2_10_11 • 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.
Shuttle Test & VAS • Visual Analogue Scale No breathlessness Greatest Breathlessness 1 10 CResp Wk 10_ Tut 2_10_11
Variations on a theme CResp Wk 10_ Tut 2_10_11 Intubated and ventilated patient Paediatrics and neonates Always remembering clinical features of hypoxaemia and hypercapnia
Clinical Features of Hypoxaemia CResp Wk 10_ Tut 2_10_11 Cyanosis Tachypnoea Tachycardia → arrhythmias/ bradycardia Peripheral vasoconstriction Respiratory muscle weakness Restlessness → confusion → coma
Clinical Features of Hypercapnia CResp Wk 10_ Tut 2_10_11 Flapping tremor of hands Tachypnoea Tachycardia → bradycardia Peripheral vasodilatation leading to warm hands and headache Respiratory muscle weakness Drowsiness → hallucinations → coma Sweating
Then … CResp Wk 10_ Tut 2_10_11 • 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
An example of one problem for a patient with newly diagnosed Bronchiectasis CResp Wk 10_ Tut 2_10_11 • 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
Goals CResp Wk 10_ Tut 2_10_11 • Should be S.M.A.R.T • Simple • Measurable • Achievable • Realistic • Time scaled
In conclusion CResp Wk 10_ Tut 2_10_11 • 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
Learning outcomes CResp Wk 10_ Tut 2_10_11 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
Bibliography CResp Wk 10_ Tut 2_10_11 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.