Examination and Assessment handbook (1) Flashcards
What is the examination and assessment of the cardiorespiratory
directed at answering?
- What clinical problems does the patient have for which physiotherapy may be helpful?
- Are the any considerations which might influence the choice of treatment?
What comes under subjective history
What the patient tells you
Case notes
patient observation charts
history of presenting condition
past medical and surgical history
social history
drug history
Dyspnoea measures
visual analogue scale
numerical rating scale
modified borg scale
MRC breathlessness scale
What comes under objective assessment
What you see and find for yourself
Observation
cough
breathing pattern assessment
auscultations
Subjective History
A patient with a cardiorespiratory condition may need additional
time to answer questions
Patients with cardiorespiratory problems will have a lots of information in their case notes become familiar with this information before doing the assessment and examination of the patient
Case Notes
DIAGNOSIS:
1.History of Presenting Condition – e.g. From Accident & Emergency or notes
- Past Medical & Surgical History
- Test Results e.g. Full blood count (FBC), arterial blood gases (ABGs), pulmonary function tests (spirometry), sputum culture (MC&S).
4.Imaging e.g. Chest X-ray (CXR), CT Thorax, Thoracic Ultrasound (TUS)
Patient’s Observation Charts
Heart Rate (HR)
Blood Pressure (BP)
Respiratory Rate (RR)
Temperature
History of Presenting Condition
Details of the onset of this episode of illness may be indicated in the case notes.
History of Presenting Condition
What should you do about the problems/symptoms identified by the patient
Make certain of them in person
History of Presenting Condition
Name the symptoms
- Dyspnoea (unpleasant sensation of breathlessness) at rest and/or on exertion.
- Orthopnoea (breathless when lying down flat)
- Cough symptoms – dry/productive/tickly
- Sputum – volume/colour/viscosity - change from usual
• Chest pain – nature (to differentiate cardiac angina pain from MSK thoracic
pain)
• Wheeze or chest tightness
History of Presenting Condition
What should you ascertain for the symptoms
- when it started
- Is it getting better or worse?
- Is it continuous or intermittent?
- What aggravates or eases it?
History of Presenting Condition
How would you get the patient to quantify the problem
- amount and colour of sputum
- numerical rating scale for pain / dyspnoea
- number of stairs patient can climb / how far they can walk without stopping
History of Presenting Condition
For each symptom how does it compare now to normally?
Treatment so far for this episode of illness and its effect, including current medication and any physiotherapy.
Past Medical & Surgical History
What are the Questions you ask?
Original onset or diagnosis of the condition if different to above?
Course of the condition, including any exacerbations, hospital admissions or physiotherapy?
Any other respiratory problems?
Any cardiac problems?
Any other medical illnesses past or present?
Any previous surgery and response to it?
Social History (from patient and/or relative/carer)
Social circumstances living alone?
Type of accommodation? Stairs?
Normal activity levels & usual functional capacity – obtain specific measure of their exercise capacity e.g. how far or long they can walk for, how frequently they exercise.
Smoking History – how long, how many per day, when gave up (if relevant).
Occupation?
Hobbies?
Pets?
Any family history of cardiac or respiratory conditions?
Drug History (from patient or their paper/electronic notes)
Respiratory Medication
- Bronchodilators – inhalers or nebulisers, ask about frequency, dose, relief provided
- Antibiotics – oral, IV or inhaled
- Steroids – long or short-term use, oral or inhaled
• Oxygen – method of delivery, long or short-term use
Analgesia (pain relief)
Non respiratory medication
Dyspnoea Measures
Sensation of breathlessness is subjective, there are measures that quantify an aspect to this sensation.
Similar to pain scales.
Dyspnoea Measures
Visual Analogue Scale
10cm line ask the patient what level they are experiencing
Minimal dysponea🤗I———————————l🤢Maximum
Numerical Rating Scale
Ask patient a number they are feeling breathless out of 10
Modified Borg Dyspnoea Scale
Show patient a scale and get them to point which applies to them
0 Nothing at all
0.5 Very, very slight (just noticeable)
1 Very slight
2 Slight
3 Moderate
4 Somewhat severe
5 Severe
6 More severe
7 Very severe
8 more severe
9 Very, very severe (almost maximal)
10 Maximal
Medical Research Council (MRC) Breathlessness Scale
Grade
1 Not troubled by breathlessness except on strenuous exercise
2 Short of breath when hurrying or walking up a slight hill
3 Walks slower than contemporaries on level ground because of breathlessness, or has
to stop for breath when walking at own pace
4 Stops for breath after walking about 100m or after a few minutes on level ground
5 Too breathless to leave the house, or breathless when dressing or undressing
Objective Assessment
“look, listen and feel” format (observation, auscultation, palpation)
followed by any other special tests required.
If patients may be acutely unwell, the more medicalised
A-B-C-D-E assessment is used.
Observation
Body parts
General
Face
Trachea
Thorax
Abdomen
Hands ankle
General observation
Position in the bed
Level of Consciousness (Alert, responsive to Voice, responsive to Pain
or Unresponsive; AVPU)
Attachments/Equipment e.g. drips, drains, oxygen
Signs of pain/anxiety/fatigue
Face observation
Colour e.g. flushed, pale, blue (central cyanosis = severe hypoxia)
Trachea observation
Trachea Centrally positioned or deviated to one side
Thorax observation
Thorax Shape e.g. barrel chest, funnel chest, scoliosis, kyphosis
Surgical Scars – previous thoracic or cardiac surgery
Abdomen observation
Abdomen Distension / obesity
Hands observation
Hands Finger clubbing (nail bed bulging associated with chronic
cardiorespiratory disease)
Tremor or flapping (associated with increased C02)
Nicotine stains
Blue fingers (peripheral cyanosis = inadequate peripheral circulation)
Ankle observation
Ankles Oedema (cardiac failure, immobility, poor venous return)
Cough
Cough is a prominent symptom forpatients with cardiorespiratory disease
Assessment of it can provide important information
The importance of coughing and different types of patients
Most patients will cough readily
some will present with a weak, ineffective or absent cough.
The ability to cough is an essential part of airway defence and should
always be assessed thoroughly
Type of cough and description
Dry :Clear cough sound with no audible respiratory secretions.
NB// Does not necessarily mean there is no sputum
Wet :Audible secretions in the lower respiratory tract
Rattling :Audible secretions in the upper respiratory tract
Productive : Patient is expectorating (spitting out) sputum after coughing
Need to describe the sputum (see below)
Type of sputum
Description
Implication
1)Clear - Saliva-like Not indicative of infection
2)Mucoid - White/milky, opaque Viral infection or non-infective
bronchitis
3) Purulent - Yellow/Green, pus-likeBacterial infection (colour is from dead neutrophils)
4) Frothy -Pink or white froth Pulmonary oedema
5)Frank
haemoptysis- Pure blood Pulmonary haemorrhage, TB, tumour,
cavity, lung infarction, pulmonary embolus.
6)Streaked
haemoptysis- Blood mixed with white/purulent sputum Inflammation of bronchial tree, tumour, cavity
Breathing Pattern Assessment
Observe the patient’s breathing pattern for one minute at rest and consider the following:
See notes
Auscultation
A stethoscope is used to listen to the chest and identify normal and abnormal sounds
Used as an investigation and outcome measure
Auscultation
Preparation
• Eliminate noise: close door, turn off radios/ TV.
• Patient :sitting up in bed or a chair. If possible patient
should not be leaning against anything – they may need help to sit forwards.
- Ask the patient to take their top off (if possible) or ask permission to move the patient’s clothing out of the way - your stethoscope should be touching the patient’s bare skin.
- Always ensure patient comfort. Be considerate and warm the diaphragm of your stethoscope with your hand before auscultation.
Auscultation
Procedure
• posterior chest: ask the patient to keep both arms crossed in front of his/her chest, if possible.
• Ask the patient to breathe deeply through the mouth. Be careful of
hyperventilation. Listen to at least one full inspiration & expiration in each location.
• It is important that you always compare what you hear with the opposite side.
e.g. If you are listening to the left apex, you should follow through by
comparing what you heard with what you hear at the right apex.
• Generally, listen to at least 6 locations on both the anterior and
posterior chest.
• Begin by auscultating the apices of the lungs, moving from side to side and comparing as you approach the bases.
Palpation
Palpation is used as part of the assessment to further investigate the observed and auscultated findings.
An explanation for palpation should be provided and consent obtained from the patient.