RET 1024L Introduction to Respiratory Therapy Lab

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RET 1024LIntroduction to Respiratory TherapyLab

• Module 4.0
• Bedside Assessment of the Patient I

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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

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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 patients
  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

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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
• Hyperthermia ?body temperature
• AKA fever or febrile
• Increases metabolic rate (? oxygen consumption, ?
  CO2 production), accompanied by ? circulation and
  ? ventilation to maintain homeostasis possible
  respiratory failure

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Body Temperature - Hypothermia (?body
  temperature)
• Caused by
• Excessive heat loss (e.g., prolonged exposure to
  cold)
• Inadequate heat production
• Impaired hypothalamic thermoregulation (e.g.,
  head injury, stroke)

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Body Temperature - Hypothermia (?body
  temperature)
• Clinical signs
• Decreased pulse and respiratory rate
• Patient indicates coldness
• Shivering (generates heat)
• Pale or bluish cool, waxy skin
• Hypotension
• Disorientation
• Drowsy or unresponsive
• Coma

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Body Temperature
• Measured
• Oral (most common), about 1? F lower than rectal
  temp
• Axilla (1? - 2? F lower than oral temp)
• Rectum (1? higher than oral temp)
• Ear (tympanic membrane), reflects core temp

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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

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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

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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)
• Bradycardia lt 60 beats/min
• Physically fit athletes
• Hypothermia
• Head injury
• Side effects of medication
• With certain cardiac arrhythmias

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Pulse Rate
• Tachycardia gt 100 beats/min
• Exercise
• Fear
• Anxiety
• Low blood pressure (hypotension)
• Anemia
• dehydration
• Fever
• ? arterial blood oxygen (hypoxemia)
• Certain medications

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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

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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
• Weak ventricular contractions combined with
  inadequate blood volume will result in in a weak
  thready pulse
• Increased heart rate combined with a large blood
  volume with generate a full, bounding pulse

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Pulse Rate
• Pulsus paradoxus pulse increases markedly in
  strength during inspiration and decreases back to
  normal during exhalation common among patients
  experiencing severe asthmatic episodes
• Pulsus alternans strength of patients pulse
  varies every other beat while the rhythm remains
  regular (left-sided heart failure)

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Respiratory Rate
• Normal resting rate
• Newborn (30 60 breaths/min)
• Toddler (25 40 breaths/min)
• Preschool (20 25 breaths/min)
• Adult (12 20 breaths/min)

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Respiratory Rate
• Ideally counted when the patient is not aware
• Counted by watching the chest wall and abdomen
  move in and out
• One good method is to count the respiratory rate
  immediately after taking the pulse, while leaving
  the fingers over the patients artery

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Respiratory Rate
• Tachypnea abnormally high respiratory rate
• Exertion
• Fever
• Arterial hypoxemia
• Metabolic acidosis
• Anxiety
• Pain

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Respiratory Rate
• Bradypnea slow respiratory rate
• Head injuries
• Hypothermia
• Side effect of certain medications (narcotics)
• Sever myocardial infarction
• Drug overdose

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Respiratory Pattern
• Note pattern of respiration
• Apnea no breathing
• Asthmatic breathing prolonged exhalation
• Kussmauls deep and fast (associated with
  diabetic acidosis)

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Respiratory Pattern
• Note pattern of respiration
• Cheyne-Stokes increases and decreases in depth
  and rate with periods of apnea (low cardiac
  output as in CHF)
• Biots similar to Cheyne-Stokes except tidal
  volumes are identical in depth (increased
  intracranial pressure)

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Respiratory Rate
• Note pattern of respiration
• Apneustic sustained inspiratory effort (damage
  to pons associated with head trauma, severe brain
  hypoxemia, lack of blood flow to brain)

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Blood Pressure (BP)
• Systolic pressure peak pressure exerted in the
  arteries during contraction of the left ventricle
• Adult normal 90 140
• Diastolic pressure in arteries after relaxation
  of the ventricles
• Adult normal 60 90
• Pulse pressure difference between systolic and
  diastolic blood pressure
• Adult normal 35 40

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Blood Pressure (BP)
• Recorded as systolic / diastolic (e.g., 120/80 mm
  Hg)
• Hypertension BP persistently elevated
• e.g., systolic gt 140 or diastolic gt 90
• Factors associated with hypertension include
  arterial disease, obesity, a high serum sodium
  level, pregnancy, obstructive sleep apnea, a
  family history of high blood pressure
• Can cause headaches, blurred vision, confusion,
  renal failure (uremia), CHF, cerebral hemorrhage,
  leading to stroke

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Blood Pressure (BP)
• Recorded as systolic / diastolic (e.g., 120/80 mm
  Hg)
• Hypertension
• Headaches
• Tinnitus
• Light-headedness, confusion
• Easy fatigability
• Cardiac palpitations
• Blurred vision
• Renal failure (uremaia), CHF, cerebral
  hemorrhage, leading to stroke

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Blood Pressure (BP)
• Recorded as systolic / diastolic (e.g., 120/80 mm
  Hg)
• Hypertension
• Hypertensive crisis an acute, severe elevation
  of BP causing neurological, cardiac, and renal
  failure
• Sustained hypertension leads to thickening and
  inelasticity of the arterial walls and resistance
  to blood flow. This process in turn causes the
  left ventricle to distend and hypertrophy. Left
  ventricular hypertrophy may lead to congestive
  heart failure (CHF).

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Blood Pressure (BP)
• Hypotension BP lt 90/60 mm Hg
• Blood pressure is not adequate for normal
  perfusion and oxygenation of vital organs
• Associated with peripheral vasodilation,
  decreased vascular resistance, hypovolemia, and
  left ventricular failure
• Analgesics (pain relievers) such as Demerol and
  morphine
• Severe burns
• Prolonged diarrhea and vommitting

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Blood Pressure (BP)
• Postural hypotension abrupt fall in BP when
  standing
• Occurs in hypovolemic patients
• May cause syncope (fainting)
• Confirmed by measuring BP in sitting and supine
  positions
• Treated with administration of fluid or
  vasoactive drugs

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Bedside Assessment of the Patient

• Physical Examination
• Measuring BP
• Commonly measured using auscultation
• Sphygmo-manometer and stethoscope
• BP cuffs come in different sizes

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Bedside Assessment of the Patient

• Physical Examination
• Measuring BP
• Most BP cuffs are marked with an O or an ?
  indicating where the cuff should be placed over
  the brachial artery

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Bedside Assessment of the Patient

• Physical Examination
• Measuring BP
• Palpate the brachial artery and then wrap the
  deflated cuff snugly around the patients upper
  arm, ensuring it is properly positioned over the
  brachial artery. The lower edge should be about
  1 inch above the antecubital fossa

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Bedside Assessment of the Patient

• Physical Examination
• Measuring BP
• Grasp the inflation bulb in such a way that you
  can inflate the cuff and, with your thumb and
  index finger, easily open and close the valve

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Bedside Assessment of the Patient

• Physical Examination
• Measuring BP
• While palpating the brachial pulse, inflate the
  cuff to approximately 30 mm Hg above the point at
  which the pulse can no longer be felt

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Bedside Assessment of the Patient

• Physical Examination
• Measuring BP
• Place the diaphragm of the stethoscope over the
  artery and deflate the cuff at a rate of 2 3 mm
  Hg/sec while observing the manometer

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Bedside Assessment of the Patient

• Physical Examination
• Measuring BP
• The systolic pressure is recorded at the point at
  which the first Korotkoff sounds are heard. The
  point at which the sounds become muffled is the
  diastolic pressure

Korotkoff sounds partial obstruction of blood
flow creating turbulence and vibration
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Bedside Assessment of the Patient

• Measuring BP

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Bedside Assessment of the Patient

• Physical Examination
• Vital Signs
• Pulse oximetry
• Establishes an immediate baseline SpO2 value
• Excellent monitor by which to assess the
  patients response to respiratory care
• Adult normal 95 - 99
• Values between 91 - 94 represent mild hypoxemia
• May not require supplemental oxygen
• Values between 86 - 90 indicate moderate
  hypoxemia
• Requires supplemental oxygen
• Values below 85 indicate severe hypoxemia
• Warrant immediate medical attention

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Bedside Assessment of the Patient

• SpO2 and PaO2 Relationship for the Adult and
  Newborn
• Adult Newborn
• Oxygen Status SpO2 PaO2 SpO2 PaO2
• Normal 95-99 75-100 91-96 60-80
• Mild hypoxemia 90-95 60-75 88-90 55-60
• Moderate hypoxemia 85-90 50-60 85-89 50-58
• Severe hypoxemia lt85 lt50 lt85 lt50