RET 1024 Introduction to Respiratory Therapy

1. RET 1024Introduction to Respiratory Therapy Module 4.1 Bedside Assessment of the Patient Patient Interview, Medical History, Sensorium and Vital Signs

2. Beside Assessment of the Patient RTs are playing an increasing role in the clinical decision-making process when it comes to initiating, adjusting, or discontinuing respiratory therapy.

3. Bedside Assessment of the Patient As never before, RTs need to develop competent beside assessment skills in order gather and interpret relevant patient data

4. Bedside Assessment of the Patient Bedside assessment is the process of interviewing the patient and examining the patient for signs and symptoms of disease and the effects of treatment

5. Bedside Assessment of the Patient Two key sources of patient data • Medical History • Physical Examination

6. Bedside Assessment of the Patient Medical History & Physical Examination Data gathered initially by the interview and physical examination help identify the need for subsequent diagnostic tests

7. Bedside Assessment of the Patient Interviewing & Taking a Medical History • Provides patient perspective • Subjective information • Establishes rapport between clinician and patient • Facilitates the sharing of information and future evaluation and treatment plans • Obtains essential diagnostic information • Objective information • Monitors changes in the patient’s symptoms and response to therapy

8. Bedside Assessment of the Patient Interview skills are an art form that takes time and experience to develop

9. Bedside Assessment of the Patient Patient interviews requires … • A genuine concern for others “People don’t care how much you know until they know how much you care.” Theodore Roosevelt • Empathy • The ability to view the world from the patient’s perspective; recognition of the patient’s feelings without criticism - feeling with the patient

10. Bedside Assessment of the Patient Patient interviews requires … • The ability to listen • Active; listening is not a passive activity • Requires complete attention • Preoccupation equates to missed information • Includes observation of body language • Facial expressions, eye movement, pain grimaces, restlessness, sighing

11. Bedside Assessment of the Patient Structure and Technique for Interviewing • Introduction • Address patient by his or her surname, using Mr., Mrs., Senor, Senora. • Introduce self and explain purpose of visit • Observe social space; 4 – 12 feet away from patient • Ensure privacy • Pull curtains if in semi-private room • Partially close door of room • Prevent interruptions

12. Bedside Assessment of the Patient Structure and Technique for Interviewing • To Begin The Interview • Move closer to patient; observe personal space; 2 – 4 feet • Assume physical position at same level of patient (pull up a chair next to the bed) • Use appropriate eye contact

13. Bedside Assessment of the Patient Structure and Technique for Interviewing • Questions and statements used in a conversational interview • Closed Questions; focus on specific information, provide clarification • “When did your cough start?” • Open-ended questions; encourages patients to describe events and priorities as they see them, helping bring out concerns and attitudes and promote understanding • “What brought you to the hospital” or “What happened next?”

14. Bedside Assessment of the Patient Structure and Technique for Interviewing • Questions and statements used in a conversational interview • Indirect questions; less threatening because they sound like statements • “If I understand you correctly, it is harder for you to breathe now than it was before your treatment.”

15. Bedside Assessment of the Patient Structure and Technique for Interviewing • Questions and statements used in a conversational interview • Neutral questions; a subset of open-ended questions. They allow respondents to decide upon answers without overt direction or pressure from questioners • Open Ended: “What happened next?” • Closed: “Would you say that you expectorated a teaspoon, tablespoon, or half a cup?” (gives the patient a choice of responses while focusing on the type of information needed)

16. Bedside Assessment of the Patient Structure and Technique for Interviewing • Questions and statements used in a conversational interview • Reflecting (echoing); repeating words, thoughts, or feelings that the patient just stated for purposes of clarifying or stimulating elaboration from the patient • Facilitating phrases; e.g., “yes” or “I see” used with eye contact and perhaps nodding of the head, show interest and encourage patients to continue their story

17. Bedside Assessment of the Patient Structure and Technique for Interviewing • Questions and statements used in a conversational interview • Communicating empathy (support); shows your concern for the patient as a human being • “That must have been very difficult for you.”

18. Bedside Assessment of the Patient Structure and Technique for Interviewing • Alternate Sources for a Patient History • Various factors affect the patient’s ability or willingness to provide an accurate history, e.g., age, alterations in level of consciousness, language, cultural barriers, emotional state, acuteness of the disease, etc.

19. Bedside Assessment of the Patient Structure and Technique for Interviewing • Alternate Sources for a Patient History • In such cases, family members, friends, work associates, previous physicians, and past medical records often provide a more accurate picture of the history and progression of symptoms

20. Bedside Assessment of the Patient Medical History Because dysfunctions of the respiratory system are often manifestations of other systemic disease processes, and because changes in pulmonary functions may affect other body systems, a cardiopulmonary assessment cannot be limited to the chest; a comprehensive evaluation of the patient’s entire health status is essential

21. Bedside Assessment of the Patient Medical History • Demographic data • Name, Date of birth, Race, Religion, Occupation, Etc. • Date and source of history and estimation of the reliability of the historian • Patient’s condition at time of history

22. Bedside Assessment of the Patient Medical History • Chief complaint • Reason for seeking treatment (admitting diagnosis) • History of present illness • Chronological description of each symptom • Onset • Frequency • Location • Severity • Etc.

23. Bedside Assessment of the Patient Medical History • Past medical history • Childhood diseases • Hospitalization, surgeries, injuries, accidents • Major illness • Allergies • Medications • Family history • Familial disease history • Marital history

24. Bedside Assessment of the Patient Medical History • Social / environmental history • Alcohol and cigarette consumption • Occupational links to disease • Gas / Chemical fumes • Dusts • Living arrangements • Religious and social activities • Recent travel or other event that might impact health

25. Bedside Assessment of the Patient Medical History • Review of systems • Head-to-toe review of all body systems (done by a physician, located in “History & Physical section of chart) • Eyes, ears, nose, mouth, throat • Skin • Cardiorespiratory system • Digestive system • Genitourinary system • Endocrine system • Nervous system • … and more

26. Bedside Assessment of the Patient Physical Examination • Acute problem • Abbreviated examination • Stable • More complex assessment

27. Bedside Assessment of the Patient Physical Examination • General Appearance • Facial expression • Pain • Anxiety • Alertness • Mood • Mental capacity • Respiratory distress

28. Bedside Assessment of the Patient Physical Examination • General Appearance • Diaphoresis (sweating) • Fever • Pain • Severe stress • Increased metabolism • Acute anxiety

29. Bedside Assessment of the Patient Physical Examination • General Appearance • Level of anxiety or distress • Severity of current problem • Position • Pulmonary hyperinflation • Upright, elbows braced on table

30. Bedside Assessment of the Patient Physical Examination • General Appearance • Personal hygiene • Duration and impact of illness on daily activities • May indicated psychiatric disorder • Nutritional status • Well nourished or emaciated

31. Bedside Assessment of the Patient Physical Examination • Levels of Consciousness (common clinical terms for the varying levels of depressed consciousness) • Conscious (alertness) • Evaluate sensorium • Oriented to Person, Place, Time (“oriented x 3”)

32. Bedside Assessment of the Patient Physical Examination • Levels of Consciousness (common clinical terms for the varying levels of depressed consciousness) • May occur with: • Poor cerebral blood flow or poorly oxygenated blood perfusing the brain (restless, confused, disoriented) • Chronic degenerative brain disorders • Medication side effects • Drug overdose

33. Bedside Assessment of the Patient Physical Examination • Levels of Consciousness (common clinical terms for the varying levels of depressed consciousness) • Confused • Decrease of consciousness • Slow mental responses • Dulled perception • Incoherent thoughts • Delirious • Hallucinations • Easily agitated • Irritable

34. Bedside Assessment of the Patient Physical Examination • Levels of Consciousness (common clinical terms for the varying levels of depressed consciousness) • Lethargic • Sleepy • Arouses easily • Responds appropriately when aroused • Obtunded • Awakens only with difficulty • Responds appropriately when aroused

35. Bedside Assessment of the Patient Physical Examination • Levels of Consciousness (common clinical terms for the varying levels of depressed consciousness) • Stuporous • Does not awaken completely • Decreased physical and mental activity • Responds to pain and deep tendon reflexes • Responds slowly to verbal stimuli

36. Bedside Assessment of the Patient Physical Examination • Levels of Consciousness (common clinical terms for the varying levels of depressed consciousness) • Comatose • Unconscious • Does not respond to stimuli • Does not move voluntarily • Loss of reflexes with deep or prolonged coma

37. Bedside Assessment of the Patient Physical Examination • Vital Signs • Body temperature • Pulse rate • Respiratory rate • Blood pressure • Pulse oximetry • Considered the 5th vital sign in many patient care settings

38. Bedside Assessment of the Patient Physical Examination • Vital Signs • An important part of the assessment process • Most frequently used clinical measurements • Provide useful information about patient’s clinical condition when compared with normal values and/or with a series of measurements • Abnormal vital signs • May be first clue to adverse reactions to treatment • Improved vital signs • Positive effects of treatment

39. Bedside Assessment of the Patient Physical Examination • Vital Signs • Body Temperature • Routinely measures for signs of inflammation or infection • Core Temperature: Normal – 98.6 F (37 C) – “afebrile”

40. Bedside Assessment of the Patient Physical Examination • Vital Signs • Body Temperature • Hyperthermia – body temperature • AKA: “fever” or“febrile” • Increases metabolic rate ( oxygen consumption,  CO2 production), accompanied by  heart rate and  ventilation to maintain homeostasis NOTE: This condition may eventually lead to respiratory failure

41. Bedside Assessment of the Patient Physical Examination • Vital Signs • Body Temperature • Hypothermia – body temperature • Excessive heat loss (e.g., prolonged exposure to cold) • Inadequate heat production • Impaired hypothalamic thermoregulation (e.g., head injury, stroke)

42. Bedside Assessment of the Patient Physical Examination • Vital Signs • Body Temperature • Hypothermia – body temperature • Decreased pulse and respiratory rate • Patient indicates coldness • Shivering (generates heat) • Pale or bluish cool, waxy skin • Hypotension • Disorientation • Drowsy or unresponsive • Coma

43. Bedside Assessment of the Patient Physical Examination • Vital Signs • Body Temperature • Measured • Rectum(reflects core temperature) • Ear – tympanic membrane (reflects core temperature) • Oral (most common), about 1 F lower than rectal temp • Axilla (1 - 2 F lower than oral temp)

44. Bedside Assessment of the Patient Physical Examination • Vital Signs • Pulse Rate • Palpated at various sites • Temporal • Carotid • Apical (heart) • Brachial • Radial • Femoral • Popliteal • Posterior Tibial • Dorsalis - Pedis

45. Bedside Assessment of the Patient Physical Examination • Vital Signs • Pulse Rate • Radial artery most common site to palpate pulse • Use first, second, or third finger to palpate – not thumb • Ideally, counted for 1 minute, but can be counted over 15 or 30 seconds and then multiplied appropriately to determine the pulse per minute

46. Bedside Assessment of the Patient Physical Examination • Vital Signs • Pulse Rate • Normal Rates • New born (100 – 180 beats/min) • Toddler (80 – 130 beats/min) • Child (65 – 100 beats/min) • Adult (60 – 100 beats/min)

47. Bedside Assessment of the Patient Physical Examination • Vital Signs • Pulse Rate • Bradycardia; < 60 beats/min • Physically fit athletes • Hypothermia • Head injury • Side effects of medication • With certain cardiac arrhythmias

48. Bedside Assessment of the Patient Physical Examination • Vital Signs • Pulse Rate • Tachycardia; > 100 beats/min • Exercise • Fear, anxiety • Low blood pressure (hypotension) • Anemia • Dehydration • Fever •  Arterial blood oxygen (hypoxemia) • Certain medications

49. Bedside Assessment of the Patient Physical Examination • Vital Signs • Pulse Rate • Note rhythm • Normally, rhythm is regular • Certain conditions such as inadequate blood flow and oxygen supply to the heart or an electrolyte imbalance, can cause the heart to beat irregularly

50. Bedside Assessment of the Patient Physical Examination • Vital Signs • Pulse Rate • Strength • Reflects the strength of left ventricular contraction and volume of blood flowing to the peripheral tissues • Should be strong and throbbing