Cardiopulmonary Assessment Flashcards
Where to obtain Patient’s History?
- Patient Chart
- Medical Team
History of Present Illness
- Presenting Diagnosis (Syncopal episode, Onset of symptoms, decreased exercise tolerance, Elective surgery, Emergent surgery, increasing SOB)
- Pt symptoms
- Timing and onset of symptoms (How and when symptoms occur)
Past Medical History
- Cardiac Risk factors (Smoker, Age, Family history, Cholesterol)
- Comorbidities: Other relevant medical history
- Medications: Pre admission
Social History
- Prior level of function / current level of function
- Living situation
- Occupation
- Social Support / Assistance
- Pain level
- Use of assistive device
- Other barriers
History - Hospital Course
- Surgical / Medical Course (Date & Type of surgery)
- Ventilatory status
- ICU stay
- Current Medications
- Pain control
- EKG
- Radiology
- Ultrasound
- Events during admission
Hospital lab info includes
- CBC
- Electrolytes levels
- Cardiac enzymes - Tropononins (increase when have heart attack)
- Cath, stress tests
- Current symptoms / complaints
PICC Line
- Peripherally inserted central catheter (PICC) line
- Directly to heart
- used for longer period of time for continuous infusions
- Goes to SVC or IVC and terminates at the right atrium
- Allows medication to be circulated throughout the body through the heart pump
Arteria Line
- Call nurse if you see blood
Ventilator
- Oropharyngeal 8 to 10 days
- can move a ventilator patient if they are awake and alert
Chest tube
- can mobilize patient
- Tube is between parietal and visceral pleura of the lung draining out air and fluid that can collect in that space
- Post surgical pts / pneumothorax, pleural effusion
- Note the volume and color in the tube before and after exercising
Accessory use for breathing
- SCM, scalenens, pecs, lats, traps
Breathing Rates
a. normal: 12-20 breaths per minute
b. Tachypneic: More than 20 breaths per minute
c. Bradypneic: less than 12 breaths per minute
d. Dyspneic: trying to catch breath
Pattern of Breathing - Normal excursion
- Symmetrical
- Inspiration: Expiration - 1: 2
- No accessory muscle recruitment
- NAD - no apparent distress
Pattern of Breathing - Abdominal Paradoxical Breathing
- Negative pressure created secondary to obstructive disease
- Diaphragm flattens → barrel chested
- Abdominal moves inward, upper chest moves outward with inspiration
Pattern of Breathing - Upper Chest Paradoxical Breathing
- Diaphragm contracts, abdominal and accessory muscles do not
- Common in SCI below C5
- Outward motion of abdomen, inward motion of upper chest with inspiration
Pattern of Breathing - Tripod Breathing
- Anterior lean, elbows on table / elbows on knees
- Accessory muscle use → largest recruitment pattern
Pattern of Breathing - Respiratory Distress
- Accessory muscle use
- Tachypnea → RR > 20
- SOB
- Cyanosis
- Pursed lip breathing
- Nasal flaring
- Change in metal status
- Apnea – breathing starts and stops (sleep apnea)
Body Type - Cachexia
- Muscle loss / wasting
- May or may not include loss of fat
- Seen in chronic, progressive disease
- Lack of appetite
- Fatigue
Chest type: Normal Dimension
- Thoracic cavity is elliptical in shape
- Anterior - Posterior: Lateral Diameter → 1:2
- Angulation of ribs is < 90 degrees
- Ribs articulate posteriorly at 45 degrees
Chest type: Barrel Chest
- Angulation of ribs > 90 degrees
- Ribs articulate posteriorly at < 45 degrees → more horizontal
- Increased AP Diameter (ex – 1:1)
- Common in COPD patients
Chest Type: Pectus Excavatum
- Depressed sternum
- Funnel chest
Chest Type: Pectus carinatum
- Protruding sternum
- Pigeon Chest
Flail chest
- chest moves inward with inspiration
- due to broken ribs
Kyphosis
- Exaggerated thoracic curve
Scoliosis
- Curve can impact efficiency of respiratory musculature
Systems Review: Neck
- Lines: Typically a central line
- JVD: Jugular venous distention
a. Indicates right sided heart failure
b. Assessed in sitting with neck turned
c. Positive Test → vein distended above level of clavicle - Tracheal Deviations: ipsilateral and contralateral shifts
Digital Clubbing
- Widening and flattening of the nail bed secondary to pulmonary illness
a. Hypoxemia secondary to poor gas exchange ( Occurs with CF, COPD, etc) - Angle between nail and distal phalange decreases
- Distorted angle of nail bed
Skin Integrity
i. Incision sites, coloring, ulcerations (venous vs. arterial)
ii. Capillary refill – rate blood fills capillaries
1. Normal – less than 2 seconds
2. Evaluated by having hands above heart level and testing blanching
3. Can indicate dehydration
iii. Edema (Pitting vs. Non-pitting)
IV. Cyanosis (Central vs. Pereipheral)
Pitting Edema Grading (by the time skin takes to rebound)
1+ : slight depression
2+ : less than 15 seconds
3+ : 15-30 seconds
4+ : more than 30 seconds
Central cyanosis
- Problem with heart or lungs
- R to L shunt ( irregular blood flow)
- Hypoxemia < 85%
- Blue lips
Peripheral Cyanosis
- Decreased cardiac output
- Poor blood flow to the extremity
- Blue finger tips
Level of Consciousness
a. Alert and Oriented x4
i. Name, place, date, reason for admission
b. Sedated or interactive
c. Agitation level
d. Fatigue
e. Comatose
f. Richmond Agitation Sedation Scale (RASS)
i. 0 – normal; +4 – combative; -5 – unresponsive
Heart rate
- can be evaluated at carotide, brachial, radial, precordium (over heart)
- If patient has an abnormal rate or rhythm (such as in atrial fibrillation), use auscultate precordium
technique – monitor for 30s and x2 - HR Parameters
i. Normal – 60 – 99
ii. Tachycardic > 99
iii. Bradycardic < 60
Blood Pressure - Non-invasive BP
i. Assess brachial pulse – medial to the biceps tendon
ii. Choose appropriate cuff size and location – no lines on BP eval side
1. A small cuff size can lead to a false high; a large cuff size can lead to a false low
iii. Line indicator up with brachial artery
iv. Place stethoscope over artery and pump to 30mmHg above the systolic pressure
v. release valve and let run at a rate of 2mm Hg/s
Blood Pressure - Arterial Doppler
i. Used for measure MAP – mean arterial pressure
ii. Use gel and ultra sound head to assess arterial pulse
iii. Record value when pulse is heard on doppler
iv. Used with patients who have non-pulsatile BP – VAD or CHF
Blood Pressure
i. Normal
1. SBP – 90 – 120
2. DBP – 60 – 80
ii. Hypotension
1. SBP < 90
2. DBP < 60
iii. Pre-Hypertension
1. SBP – 120 – 139
2. DBP – 80 – 89
iv. Hypertension
1. SBP > 140
2. DBP > 90
Respiratory rate
a. Normal → 12 – 20 breaths per minute
b. Tachypneic → more than 20 breaths per minute
c. Bradypneic → less than 12 beaths per minute
Ankle Brachial Index / ABI
- Used to evaluate and diagnose PAD (peripheral arterial disease)
o Signs and symptoms → limb will feel colder + shiny/hairless - Assess with brachial pulse and posterior tibialis artery or dorsalis pedis
- Assess R and L sides
- Right ABI
o HIGHER right ankle pressure/higher arm pressure - Left ABI
o HIGHER left ankle pressure/higher arm pressure - Interpretation of ABI
o >1.30 → noncompressible
o 0.91 – 1.30 → normal
o 0.41 – 0.90 → mild to moderate PAD
o 0.0 – 0.40 → severe PAD
Cardiac Auscultation - Aortic valve
- 2nd intercostal space RSB
Cardiac Auscultation - Pulmonic valve
- 2nd intercostal space LSB
Cardiac Auscultation - Tricuspid Valve
- 4th to 5th intercostal space LSB
Cardiac Auscultation - Mitral Valve
- Midclavuciular line 5th intercostal space
- PMI ( point of maximal impulse)
- Can feel the strongest pulse
S1
“Lub”
- Closing of the AV valves
- Loudest at cardiac apex
- Beginning of systole
- Auscultated with diaphragm of stethoscope
What are the two components at S1
- Tricuspid & Mitral closing
S2
“dub”
- at the end of systole, just before diastole
- Closing of the semilunar valves
- Loudest at aortic & pulmonic
- The aortic and pulmonic valves close, stopping blood from flowing back into the ventricles
S3
- Gallop
- ## Faint, early diastolic sound (Lub - Dub - pah)
