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MON 2011 - Slide 5 - E. Furlong / S. Faithfull - Choice: Assessment during therapy - Key skills workshop 1: "on treatment" review
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MON 2011 - Slide 5 - E. Furlong / S. Faithfull - Choice: Assessment during therapy - Key skills workshop 1: "on treatment" review






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  • The thoracic cavity = 12 pairs of ribs that connect in the posterior thorax to the vertebral bodies of the spinal column. In the anterior thorax, the first 7 pairs of ribs are attached to the sternum or breastbone by cartilage. The lower 5 ribs do not attach to the sternum. The 8 th , 9 th , and 10 th ribs are attached to each other by costal cartilage. The 11 th and 12 th ribs , known as “floating ribs,” are not attached in any way to the sternum; they move up and down in the anterior chest, allowing for full chest expansion. The angle of Louis (also called the sternal angle) is a useful place to start counting ribs, which helps localize a respiratory finding horizontally . If you find the sternal notch, walk your fingers down the manubrium a few centimeters until you feel a distinct bony ridge. This is the sternal angle. The 2nd rib is continuous with the sternal angle; slide your finger down to localize the 2nd intercostal space. The angle of Louis also marks the site of bifurcation of the trachea into the right and left main bronchi and corresponds with the upper border of the atria of the heart. Reference lines help pinpoint findings vertically . For example, the major division ("fissure") between lobes in the anterior chest crosses the 5th rib in midaxillary line and terminates at the 6th rib in the midclavicular line
  • Cough is a reflex response to stimuli that irritate receptors in the trachea larynx and large bronchi – dust, sputum, extreme hot or cold air, inflammation of mucosa, tumour or enlarged lymph nodes, cough may also be cardiovascular in origin (LVF), viral infection, bronchitis bilateral sinusitis, gastro oesophageal reflux Cough and sputum production ( Chapter 38 ) are common to obstructive, inflammatory, infectious, and neoplastic pulmonary processes, as well as cardiac diseases and disorders of the ears, nose, and throat. Cough is a normal defense mechanism of the respiratory tract, but when increased in severity or frequency, cough can be a cause of disease as well as an indicator of disease. Sputum production reflects the presence of inflammatory, infectious or neoplastic disease in the airways or pulmonary parenchyma. The amount and character of sputum provide the physician with helpful clues to distinguish among possible etiologies. Hemoptysis ( Chapter 39 ) is never normal and can be a warning of a serious or even life-threatening respiratory disorder. Hemoptysis must be differentiated from hematemesis and from simple epistaxis, and must be quantified in terms of volume per 24 hours for adequate assessment
  • the subjective sensation of difficulty in breathing, is probably the most common respiratory complaint and cannot be differentiated at first glance from dyspnea due to cardiac disease, neuromuscular weakness, or simple obesity. Dyspnea should always be quantified as to how much exertion is necessary to produce the sensation of breathlessness Wheezing and asthma ( Chapter 37 ) point to the presence of an obstructive airway process but may be seen in heart failure as well. Wheezing may result from airway reactivity, airway narrowing, airway obstruction, compression, tumors, aspirated foreign bodies, as well as a variety of biochemical and immunologic insults. The time course of wheezing complaints and history of precipitating causes provide important information for interpretation
  • Proliferation and edema of connective tissue result in loss of the normal angle between the skin and nail plate and excessive sponginess of the nail base. Clubbing is usually acquired and is associated with certain cardiopulmonary and gastrointestinal disorders, but may occur in congenital or familial forms. Acropachy is an alternative term for clubbing. Acquired clubbing is often reversible when the associated condition is treated successfully. Two signs are characteristic of early clubbing: the "floating nail" sign and the "profile" sign.
  • Palpation Posterior chest wall 1 . level of clavicle 2. 2nd intercostal space 3. 4th intercostal space 4. 6th intercostal space Palmer surface of hand and finger pads – to assess size, consistency, texture of a mass, depressions, bulges, paradoxical movements, temperature, tenderness or surgical emphysema Dorsal surface - to assess vibrations
  • Percussion of the thorax attempts to assess the state of the pulmonary parenchyma, whether it is filled normally with air, consolidated or hyperinflated. Percussion may also detect obliteration of the pleural space by fluid (pleural effusion) or by air (pneumothorax). Percussion notes are described as normal or resonant, tympanitic, and dull
  • Palpation Anterior chest wall 1 . 2nd intercostal space 2. 4th intercostal space 6th intercostal space Tactile fremitus -palpable vibrations transmitted through the bronchopulmonary tree to the chest wall during speech. Fremitus is decreased when Voice is soft When transmission of voice sounds from larynx to surface of chest wall is impeded due to e.g fibrosis,pleural effusion ,pneumothorax Method Use ball of hand or ulnar surface of hand Compare right and left side of chest simultaneously Ask patient to repeat “99” as each point is palpated

MON 2011 - Slide 5 - E. Furlong / S. Faithfull - Choice: Assessment during therapy - Key skills workshop 1: "on treatment" review MON 2011 - Slide 5 - E. Furlong / S. Faithfull - Choice: Assessment during therapy - Key skills workshop 1: "on treatment" review Presentation Transcript

  • Assessment during therapy: Key skills workshop ‘on treatment’ review Eileen Furlong ESO-EONS Masterclass
  • Eileen Furlong ESO-EONS Masterclass “ As far as Edward Bear knew, it was the only way of coming downstairs, although he sometimes felt there was another way, if only he could stop bumping for a moment and think about it” (AA Milne)
  • Discussion
    • What assessment skills do you use in practice everyday?
    • What nursing framework do you utilise ?
    • Nursing models of care
    Eileen Furlong ESO-EONS Masterclass
  • Aim of this session
    • Application of clinical assessment skills
    • Focus on respiratory skills
    • Patient case scenario
    • Demonstration and practice
    • Interactive
    Eileen Furlong ESO-EONS Masterclass
  • The objective for this session is to teach you skills to be able to: Describe and perform the techniques used in respiratory assessment Describe and identify normal and abnormal assessment findings Respiratory Assessment Review respiratory anatomy & physiology & history taking
  • Respiratory Anatomy & Physiology Anatomy Physiology Pulmonary gas exchange
    • Topography
    • Lobes and fissures
    Important lndmarks of the Chest
    • Cough
    • Shortness of breath
    • Chest pain with breathing
    • Wheezing
    • Haemoptysis
    • PQRST
    • P rovocative
    • Q uality/ Quantity
    • R egion or radiation
    • S everity
    • T iming
    • U nderstanding
    • Morton (1993)
    • OLD CART
    • O nset
    • L ocation
    • D uration
    • C haracteristic
    • A ssociated factors
    • R elieving /aggravating factors
    • T reatment
    • Seidel et al (2003)
    Common Symptoms Remember The Health History or
            • Do you have a cough?
      • Onset: When did it start? gradual or sudden?
      • Location: Associating Features: is it painful, is it tiring?
    • Duration: How long have you had it? <3weeks, 3-8 weeks > 8 weeks
    • Frequency-how often do you cough?
        • Timing: day or night, just in morning, does it wake you up?
        • Weight gain, loss, energy levels?
    • Characteristic: Quality: how would you describe your cough?
      • Quantity & Severity: is it dry or do you cough up any sputum?
      • How much, colour & consistency, is there any blood?
      • If blood stained, is it frank, dark or bright red?
    • Associated factors/ aggravating factors : Allergies, activity, position, fever,
    • talking, anxiety, smoking habits, current medications,
    • history of lung diseases such as bronchitis, pneumonia,
    • emphysema, Asthma, frequent colds
    • Relieving factors? What makes it better or worse?
    • Treatment: Over the counter/prescripton medications, rest, position change
    • Are you concerned about the cough?
      • Have you ever had or have difficulty breathing?
      • Onset: When did it start? gradual or sudden? exercise or at rest?
      • Location: Associating Features: do you experience chest pain? other pain, cough, wheezing sound, bluish lips, anything unusual re nails
    • Duration: How long does it last?, Frequency-how often does it occur?
        • Timing: specific time -day or night?
        • Weight gain, loss, energy levels?
    • Characteristic: How severe is it? Are you able to continue talking, walking?
    • Associated factors/ aggravating factors : What brings it on, exercise, anxiety?
    • Have you difficulty breathing when you lie flat-number of pillows to get
    • comfortable? Do you awake from sleep/does sitting up help?
    • Allergies, smoking habits, current medications, past history of
    • lung diseases , frequent colds, recent trauma
    • Relieving factors? What makes it better or worse?
    • Treatment: Any treatments?
    • Are you concerned about your breathing?
    • How does it affect your work or home activities?
    Shortness of Breath
    • Wheezing
      • Wheezes are musical respiratory sounds that may be audible to the patient and to others
    • Haemoptysis
      • Haemoptysis is the coughing up of blood from the lungs; it may vary from blood-streaked phlegm to frank blood
      • Ask the patient to describe the volume of blood produced as well as other sputum attributes
      • Try to confirm the source of the bleeding by history and examination before using the term “haemoptysis”; blood may also originate from the mouth, pharynx, or gastrointestinal tract
    Wheezing, haemoptysis
  • Physical Examination of the Posterior Chest
    • I - Inspection
    • P - Palpation
    • P - Percussion
    • A – Auscultation
    • Scope of practice
    • Technique
    Eileen Furlong ESO-EONS Masterclass
    • Initial survey of respiration and the thorax
      • Observe the rate, rhythm, depth, and effort of breathing
      • Inspect for any signs of respiratory difficulty
        • Assess the patient’s color – central & peripheral
        • Listen to the patient’s breathing
        • Inspect the patient’s neck
      • Observe the shape of the chest
      • Inspect for clubbing of fingers
    Techniques of examination
    • Examination of the posterior chest
      • Inspection
        • From a midline position behind the patient, note the shape of the chest and the way in which it moves
      • Palpation
        • Assess any observed abnormalities and identify any tender areas
        • Test chest expansion: place thumbs at the level of the 10th rib with fingers loosely grasping and parallel to the lateral rib cage; watch the distance between the thumbs as they move apart during inspiration
        • Feel for tactile fremitus, or palpable vibrations
        • as the patient is speaking
    Techniques of examination cont.
    • Examination of the posterior chest
      • Percussion
        • Perform from side to side to assess for asymmetry
        • Strike using the tip of your tapping finger
        • Use the lightest percussion that produces a clear note
        • Percussion helps establish whether the underlying tissues (5-7 cm deep) are air-filled, fluid-filled, or solid
        • Percussion notes
          • Resonance
          • Flatness,
          • Dullness
          • Hyperresonance
          • Tympany
    Techniques of examination cont.
    • Examination of the posterior chest
      • Auscultation
        • Auscultation of the lungs is the most important examination technique for assessing air flow through the tracheobronchial tree
        • Together with percussion, it also helps to assess the condition of the surrounding lungs and pleural space
        • Listen to the breath sounds with the diaphragm of a stethoscope after instructing the patient to breathe deeply through an open mouth
        • Use the pattern suggested for percussion, moving from one side to the other and comparing symmetric areas of the lungs
        • Listen to at least one full breath in each location
    Techniques of examination cont.
    • Examination of the anterior chest
      • As for examination of the posterior chest, proceed in an orderly fashion: inspect, palpate, percuss, and auscultate
      • With percussion, the heart normally produces an area of dullness to the left of the sternum from the 3rd to 5th rib interspaces
      • Supraclavicular retraction is often present
    Techniques of examination cont. Palpation Percussion Auscultation
  • Case Scenario Eileen Furlong ESO-EONS Masterclass
  • Personal / Social / Family History
    • Rosa – 56 year old female
    • Separated from her husband 5 years ago
    • Has two male children (26 years and 28 years)
    • Does not work outside of the home
    • Father died from Lung Cancer
    • Mother died from MI
    • Two sisters and one brother alive and well
    • Smoker: 10-15 cigs daily x 30 years
    • Social drinker: approx 7 units weekly
    Eileen Furlong ESO-EONS Masterclass
  • Medical History
    • Diagnosed with Right Breast Cancer in 2005
    • Had right mastectomy and axillary clearance
    • 2.5 cms, Grade 3, 8/37 LN+, ER+
    • Adjuvant chemotherapy: TAC (Taxotere, Doxorubicin, and Cyclophosamide) x 6 on BCIRG oo5 Trial
    • Adjuvant radiotherapy
    • Hormonal Therapy: Tamoxifen x 3 yrs/Femara x 2 yrs
    • History of rheumatoid arthritis x 4 years (right wrist and left shoulder) and osteoporosis in lumbar spine
    Eileen Furlong ESO-EONS Masterclass
  • Chief Complaint
    • “ I feel a bit breathless and I have a pain in my right side”
    Eileen Furlong ESO-EONS Masterclass
    • Pain
    • Cough
    • Shortness of breath
    • Chest pain with breathing
    • Wheezing
    • Haemoptysis
    • OLD CART
    • O nset
    • L ocation
    • D uration
    • C haracteristic
    • A ssociated factors
    • R elieving /aggravating factors
    • T reatment
    • ( Seidel et al. 2003)
    Remember The Health History
  • History of Present Illness
    • Onset: Two days ago
    • Location: Chest and lower back
    • Duration: Used to go when I rested but now all the time
    • Characteristics: Dull aching pain at the back of lung area on right side
    • Aggravating factors: Worse at night in bed and when coughing
    • Relieving factors: Nothing
    • Treatment: Cough mixture and OTC analgesia
    Eileen Furlong ESO-EONS Masterclass
  • Findings
    • Respiratory – vital signs, colour, respiratory effort
    • Chest palpation: tenderness over lower right lateral/posterior rib cage between mid-axillary line and posterior axillary line.
    • Chest expansion slightly reduced
    • Resonant to percussion
    • Lungs clear on auscultation
    Eileen Furlong ESO-EONS Masterclass
  • Second Case
    • Katie 28 year old with diagnosis of Hodgkins lymphoma received 6 cycle of AVBD (Adriamycin,Vinblastine,Bleomycin,Dacarabazine )
    • Showed Partial response with ABVD
    • 2 nd line therapy planned with DHAP (cytarabine,cisplatin)
  • Chief Complaint
    • “ I feel tired and do not feel right”
    Eileen Furlong ESO-EONS Masterclass
  • Continued
    • Presented to the oncology unit a week later post Cycle 1 of DHAP
    • On admission temperature 38.9 degrees centigrade, blood pressure 93/71 mm of hg ,pulse rate 124/minute
    • Complained of cough ,dyspnoea on exertion
    • Grade 2 fatigue (National Cancer Institute Grading )
    • Wcc 0.9 x 10 9 /l
    • Neutrophils 0.1x10 9 /l
  • Right lower lobe consolidation
  • Findings
    • IPPA
    • Inspection: Normal
    • Palpation: Resp Expansion Fremitus
    • Percussion: Dull on right
    • Auscultation: Adventitious sounds, vesicular sounds
    • Chest X-ray : Consolidation in right lower lobe .
    Eileen Furlong ESO-EONS Masterclass
  • Eileen Furlong ESO-EONS Masterclass Do you see the Dalmatian in the picture? • Clinical experience sometimes prevents seeing the right picture • Now that you see it, can you try to not see it? • Experience can result in ideas that are difficult to change
  • Eileen Furlong ESO-EONS Masterclass