Cardio pulmonary assessment Flashcards
orthopnea
pt cannot lie flat
- has to have elevation to head for breathing purposes
Tests and measures
1) pulmonary function test(PFT)
2) CXR
3) ABG analysis
4) Oximetry
5) blood cell count, electrolytes
6) cardiovascular imaging
7) GXT
physical examination
1) inspection/observation
2) palpation/percussion
3) auscultation
4) cough assessment
5) functional capacity(response to activity, bed mobility)
level of consciousness
alert, agitated, confused, semicomatous, comatous
level of distress
chest discomfort, dyspnea, anxiety, fatigue, dizziness
body type
obese, normal, cachectic
skin tone and color
cyanosis, edema, pallor, digital clubbing
edema in foot
poor venous return or CHF
- if pitting edema, probably CHF
posture
kyphosis, scoliosis, positioning
neck
jugular vein distension, accessory muscle use in breathing
chest shape
A-P diameter, chests deformity(Barrel, pigeon, funnel chest)
abdomen
enlarged liver, spleen, or ascites
normal respiratory rate
newborns = 44 breaths per minute infants = 20-40 Bpm preschool = 20-30 Bpm older children = 16-25 Bpm adults = 14-18 Bpm
indicators of increased work of breathing
- dyspnea
- increased TV
- increased respiratory time
- soft tissue retractions
- nasal flaring
- accessory muscle use
- adventitious breath sounds
factors affecting respiratory pattern
- pain
- emotion
- body temp
- sleep
- body position
- activity level
- presence of disease
diaphragmatic excursion
step 1 = pt breathes deeply and hold, locate diaphragm position
step 2 = pt exhales, locate diaphragm position again
step 3 = difference between the two levels(3-5 cm)
cough assessment
effectiveness = ability to clear secretions
control = ability to start and stop coughs
quality = wet, dry, bronchospastic
frequency
color = hemoptysis, quantity, odor, consistency
cough mechanism
4 phases:
1) full, deep inspiration
2) closure of glottis
3) abdominal contraction
4) rapid expulsion of air forcing sudden opening of glottis
dyspnea scale: 0
not troubled with breathlessness except with strenuous exercise
dyspnea scale: 1
troubled by shortness of breath when hurrying on level ground or walking up a slight hill
dyspnea scale: 2
walks slower with people of the same age on level ground because of SOB, or has to stop for breath when walking at own pace on level ground
dyspnea scale: 3
stops for breath after walking about 100 meters or after a few minutes on level ground
dyspnea scale: 4
too SOB to leave the house or is SOB when dressing or undressing
of MET’s for ADL’s
at least 5
