RET 1024 Introduction to Respiratory Therapy

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RET 1024Introduction to Respiratory Therapy

• Module 4.0
• Bedside Assessment of the Patient

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Beside Assessment of the Patient

• RTs are playing an increasing roll in the
  clinical decision-making process when it comes to
  initiating, adjusting, or discontinuing
  respiratory therapy.

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Bedside Assessment of the Patient

• As never before, RTs need to develop competent
  beside assessment skills in order gather and
  interpret relevant patient data

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Bedside Assessment of the Patient

• Bedside assessment is the process of
  interviewing the patient and examining the
  patient for signs and symptoms of disease and the
  effects of treatment

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Bedside Assessment of the Patient

• Two key sources of patient data
• Medical History
• Physical Examination

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Bedside Assessment of the Patient

• Interviewing Taking a Medical History
• Provides patient perspective
• Subjective information
• Establishes rapport between clinician and patient
• Facilitates the sharing of information and future
  evaluation and treatment plans
• Obtains essential diagnostic information
• Objective information
• Monitors changes in the patients symptoms and
  response to therapy

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Bedside Assessment of the Patient

• Interview skills are an art form that takes
  time and experience to develop
• T. Des Jardins, G. Burton

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Bedside Assessment of the Patient

• Patient interviews requires
• A genuine concern for others
• Empathy
• The ability to view the world from the patients
  perspective recognition of the patients
  feelings without criticism - feeling with the
  patient
• The ability to listen
• Active listening is not a passive activity
• Requires complete attention
• Preoccupation equates to missed information
• Includes observation of body language
• Facial expressions
• Eye movement
• Pain grimaces
• Restlessness
• Sighing

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Bedside Assessment of the Patient

• Structure and Technique for Interviewing
• Introduction
• Address patient by his or her surname, using Mr.,
  Mrs., Senor, Senora.
• Self and purpose of visit
• Observe social space 4 12 feet away from
  patient
• Ensure privacy
• Pull curtains if in semi-private room
• Partially close door of room
• Prevent interruptions

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Bedside Assessment of the Patient

• Structure and Technique for Interviewing
• Begin interview
• Move closer to patient observe personal space 2
  4 feet
• Assume physical position at same level of patient
  (pull up a chair next to the bed)
• Use appropriate eye contact
• Review Guidelines for Effective Patient
  Interviewing Egans Fundamentals of Respiratory
  Care, Eighth Edition, Ch. 14

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Bedside Assessment of the Patient

• Structure and Technique for Interviewing
• Open-ended questions
• Used when narrative information is desirable
• To begin the interview
• To introduce a new section of questions
• To gather further information
• Enhances rapport with the patient
• Closed or Direct Questions
• Used when asking for specific information
• Solicits a short one or two-word, yes or no type
  of answer

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Bedside Assessment of the Patient

• Structure and Technique for Interviewing
• Ask questions that identify common characteristic
  of symptoms
• When did it start?
• How severe is it? (Rated on a scale of 1-10)
• Where on the body is it?
• What seems to make it better or worse?
• Has it occurred before? If so, how long did it
  last?

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Bedside Assessment of the Patient

• The best interview techniques are of no value if
  the interviewer is not knowledgeable about the
  pathophysiology and characteristics of the more
  common cardiopulmonary symptoms

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Bedside Assessment of the Patient

• Medical History
• Healthcare practitioners must be familiar with
  the medial history of the patients they are
  treating
• Signs and symptoms the patient exhibited on
  admission
• Reason for therapy

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Bedside Assessment of the Patient

• Medical History
• Chief complaint (admitting diagnosis)
• History of present illness
• Past medical history
• Major illness
• Surgeries
• Hospitalization
• Allergies
• Health-related habits

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Bedside Assessment of the Patient

• Medical History
• Social / environmental history
• Familial / Genetic links to disease
• Occupational links to disease
• Gas / Chemical fumes
• Dusts
• Review of systems
• Head-to-toe review of all body systems
• Done by physician
• Documented in History Physical

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Bedside Assessment of the Patient

• Physical Examination
• General Appearance
• Acute problem
• Abbreviated examination
• Stable
• More complex assessment

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Bedside Assessment of the Patient

• Physical Examination
• General Appearance
• Facial expression
• Pain
• Anxiety
• Alertness
• Mood
• Mental capacity
• Respiratory distress

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Bedside Assessment of the Patient

• Physical Examination
• General Appearance
• Diaphoresis (sweating)
• Fever
• Pain
• Severe stress
• Increased metabolism
• Acute anxiety

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Bedside Assessment of the Patient

• Physical Examination
• General Appearance
• Level of anxiety or distress
• Severity of current problem
• Position
• Pulmonary hyperinflation
• Upright, elbows braced on table

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Bedside Assessment of the Patient

• Physical Examination
• General Appearance
• Personal hygiene
• Duration and impact of illness on daily
  activities
• May indicated psychiatric disorder
• Well nourished or emaciated

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Bedside Assessment of the Patient

• Physical Examination
• Level of Consciousness
• Conscious (alertness)
• Evaluate sensorium
• Oriented to Person, Place, Time (oriented x 3)

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Bedside Assessment of the Patient

• Physical Examination
• Level of Consciousness
• Depressed consciousness
• Poor cerebral blood flow or poorly oxygenated
  blood perfusing the brain
• (restless, confused, disoriented)
• Chronic degenerative brain disorders
• Medication side effects
• Drug overdose

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Bedside Assessment of the Patient

• Physical Examination
• Levels of Consciousness (common clinical terms)
• Confused
• Decreased consciousness
• Slow mental responses
• Dulled perception
• Incoherent thoughts
• Delirious
• Hallucinations
• Easily agitated
• Irritable

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Bedside Assessment of the Patient

• Physical Examination
• Levels of Consciousness (common clinical terms)
• Lethargic
• Sleepy
• Arouses easily
• Responds appropriately when aroused
• Obtunded
• Awakens only with difficulty
• Responds appropriately when aroused

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Bedside Assessment of the Patient

• Physical Examination
• Levels of Consciousness (common clinical terms)
• Stuporous
• Does not awaken completely
• Decreased physical and mental activity
• Responds to pain and deep tendon reflexes
• Responds slowly to verbal stimuli

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Bedside Assessment of the Patient

• Physical Examination
• Levels of Consciousness (common clinical terms)
• Comatose
• Unconscious
• Does not respond to stimuli
• Does not move voluntarily
• Loss of reflexes with deep or prolonged coma

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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
• Hypertensive crisis an acute, severe elevation
  of BP causing neurological, cardiac, and renal
  failure

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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
• 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 organ
• 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