cardiorespiratory assessment Flashcards
what is the A to E assessment?
- Airway
- Breathing
- Circulation
- Disability
- Exposure
why is the A- E assessment used?
- provides a systematic approach to assessment
- universally understood in health care
who can the A-E assessment be used on?
- clinically deteriorating patients
describe the airway section
- is the airway patent?
- what of airway, tracheostomy, laryngectomy
- are they self- ventilating or requiring respiratory support
- any obstruction?
- are they able to talk to you?
- are they talking in full sentences or is it labored?
describe the breathing section
- look, listen & feel
- respiration rate, depth
- SpO2
- are there any respiratory support> oxygen, ventilation
- is the respiratory rate rhythmical?
- diaphragmatic movement
- chest deformity
- palpate
- cyanosis
- ABG’s
- Radiography
describe circulation section
- skin> is it mottled, blue, pink or pale
- CAP refill time (CRT)
- heart rate
- blood pressure
describe disability section
- level of consciousness
- ACVPU
- Glasglow Coma score
- blood glucose
what does ACVPU stand for in relation to disability?
- alert
- new confusion
- voice
- pain
- unreponsive
describe exposure section
- temperature
- review any wounds, bleeding
- catheters
- chest drains
- ensure that there is dignity maintained throughout
what should you ensure for the A to E assessment? (3)
- ensure it is documented
- ensure that a good clinical history is taken
- ensure that there is a continue monitoring and that there is response recorded
what are the five simple physiological measurements?
- heart rate
- blood pressure
- saturation
- arterial blood gases
- temperature
what does the subjective assessment identify?
- if patient is in immediate danger
- does patient have/ present with increased risk of developing sputum retention, loss of lung volume, increased WOB, or respiratory failure
what are common symptoms of cardiorespiratory patients?
- cough
- sputum
- breathlessness/ dyspnoea
- chest pain
- wheeze
- history of falls
- anxiety and depression
- fatigue
- swelling
- cyanosis
- reduced exercise tolerance
what should you ask about the cough?
- is it with sputum> productive cough
- is it without sputum> dry
- identify if patient is wasting energy on unproductive cough
what should you ask about sputum?
- colour
- consistency
- has it changed
- quantity produced daily
- blood present
- mucoid, mucopurulent, purulent
what should you ask about wheezing?
- when do you wheeze?
- is it on activity?
- at rest?
- cause> swelling, bronchospasm, sputum
- are there clues in PMH
what should you ask about chest pain?
- cardiac pain described as central, crushing & radiating to left arm and neck
- MSK pain due to cough but should be explored in detail to establish
- can also be due to heart related condition
what should you ask about breathlessness/ dyspnoea?
- when?
- position dependent?
- do you have anything that eases this?
what people are anxiety & depression common in?
- patients with respiratory disease
what may you notice in extreme cases of cyanosis?
- fingers are blue
what does HPC involve?
- summary of problems including information from medical notes
what does PMH involve?
- all medical and surgical conditions
what does DH involve?
- all medications and allergies
what does FH involve?
- is there a family history of cardiorespiratory conditions?
what does SH involve?
- lifestyle factors> does patient smoke? alcohol intake? physically active?
- does patient have stairs at home or are there factors that are going to present challenge
what are the main objective assessment components?
- observation
- palpation
- heart rate
- auscultation
- oxygen saturations
- temperature
- respiration rate
what should you deal with first in observation?
- is patient comfortable and well positioned with regards to lung volume/ sputum clearance
describe the observation of cardiorespiratory patients
- general appearance
- are they using accessory muscles of breathing?
- chest expansion
- can you see diaphragmatic movement?
- does the patient appear restless?
- are they talking in full sentences?
- colour> pallor
- cyanosis is a warning sign
- clubbing a loss of angle between nail bed and nail
- oedema
- clammy
- work of breathing
- are they on a ventilator?
- do they need oxygen?
what should you consider when observing cardiorespiratory patients?
- size of patient and manual handling implications
- structural posture changes affecting lung capacity (chest shape, kypotic posture, scoliosis)
describe palpation
- feel fremitus
- chest expansion> is it equal
- diaphragmatic vs apical breathing
- pump handle and bucket handle movement
- percussion
- resonant (well aerated, normal), hyper- resonant, dull (consolidated), stony dull (pleural effusion)
- any pain
what is auscultation?
- completed across the lung fields to listen to different sounds
- are breaths sounds present through chest
- any missing or added sounds?
what is normal auscultation?
- inspiration phase longer than expiration phase
what is not normal auscultation?
- added sounds
- reduced breath sounds
- wheeze
- crackles
- stridor
- plural rub
what trends should you look at?
- look at temp, BP, HR, RR
- do they fall within normal values
- any recent changes e.g., sudden increase or decrease
what impact would extreme values have on physio? - give examples
- patient who has low BP will you want to get them out of bed?
- if patient has tachycardia how much physical exertion is appropraite
what three results does a spirometer give you?
- FEV1
- FVC
- PEF
what results does ABGs give you?
- 02 removal
- C02 removal
