Cardiorespiratory Assessment


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Cardiorespiratory Assessment

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Cardiorespiratory Assessment

  1. 1. By: Gan Quan Fu, BPT
  2. 2. Definition and Purpose • An ongoing process where the patient’s status is continuously monitored and reassessed through any interaction (Smith and Ball, 1998, p.29). • Enables therapist to determine patient’s problem (Smith and Ball, 1998, p.29). • Obtain a precise database which can be use a base line for future reference (Smith and Ball, 1998, p.29). • Ensures understanding between the therapist and patient which leads to an accurate, prioritised problem list.
  3. 3. Areas of Assessment Gathering Information Subjective Assessment Objective Assessment Adapted from: Smith and Ball, 1998, p.29
  4. 4. Gathering Information • Medical notes and diagnostic test results  Information about current status, severity and factors which may influence management. • Record patient demographic data should be recorded in physiotherapy treatment notes. • Details and relevant information should be noted (ie. History, examination, investigation) should be noted. • Special note should be taken on Cardiovascular disorder since it may influence patient’s overall condition and management. • Musculoskeletal and neurological disorder may have a bearing on management should be noted.
  5. 5. Investigations/Diagnostic Tests • Blood gas analysis and HCO₃⁻ or acid-base balance  Critical info about patient respiratory status, enable therapist to determine severity and urgency of intervention require. • Partial pressure of oxygen (PaO₂) and arterial oxygen saturation (SaO₃)  Indicates level of oxygen in blood. *Reduction of O₂  system function may be impaired and nature of intervention must be carefully considered (most physiotherapeutic intervention ↑ O₂ consumption)* • Present and past chest X-ray  progression of changes over a period of time.
  6. 6. Blood gas analysis and acid-base balance in respiratory disorders Normal Values Early acute disorder/ hyperventilation may lead to respiratory alkalosis Later acute disorder may lead to respiratory acidosis Chronic disorder may lead to compensated respiratory acidosis pH 7.35 – 7.45 → ↑ ↓ → PaO₂ 12 – 14 kPa/ 90 – 105 mmHg ↓ ↓ ↓ ↓ PaCO₂ 4.5 – 6.5 kPa/ 33.8 – 48.8 mmHg → ↓ ↑ ↑ HCO₃⁻ 22 – 26 mmol/litre → → → ↑ Base excess -2 to +2 → → → ↑ Saturation 97 – 98% ↓ ↓ ↓ ↓ → = Within normal Range ↑ = Increase above normal Range ↓ = Decrease below normal Range Adapted from: Smith and Ball, 1998, p.30
  7. 7. Subjective Assessment • Obtain patient’s perspective of his/her disorder & confirm & elaborate existing data (Smith and Ball, 1998, p.30). • Form of structured conversation and not formal interview  info is elicited in relaxed manner. • Open question are encourage  more effective in gaining a fuller picture and additional relevant info. • Close question can be used  if specific yes/no is applicable. • Initial questions  Seek to gain background info, info about patient and his/her lifestyle; Proceed to  more specific questions about patient’s symptoms. *eg: begin with ‘What is the main problem?’ • Questions do not have to be asked in specific order (Try to establish smooth, logical progression from one area to another).
  8. 8. What are the initial questions?? How is it Conducted?? • Position of the Patient – In a position which they find most comfortable. • History of present complain, Drug history, Past medical history, Physiotherapy, Family history, Occupational history, Allergies, Social history, and Smoking history. *mnemonic: How Do People Pay For Only A Small Smoke
  9. 9. Initial Questions • History of Present Complain  Clarify the sequence of events which have led to hospital admission or treatment referral. • Drug History  Drug taken by patient (now & at time of admission, dose, length of time, and mode of delivery), does patient understand why he or she is taking the medication and any side- effects experienced and clarify the effectiveness of drug taken. • Medical History  Encompass all relevant facts regarding patient’s previous illness, surgery done and previous hospitalization and management.
  10. 10. • Physiotherapy  Any physiotherapy treatment in the past? (If so  when and for what) What type of treatment and was it of any value? • Family History  Any relatives suffer from same disorder? Any diseases which have been prevalent among immediate family members? • Occupational History  Relevant if patient has occupation that could predispose to respiratory or vascular condition. • Allergies  Aware of any allergies to food, drugs or external agents such as pollen/house dust mites? Can they be avoided?? Initial Questions
  11. 11. • Social History  Type of accomodation (ie. Is it all a level or there is upstairs? Live alone or? Any support from family, friends, neighbour or outside agent?), ability of patient to maintain an independent life (ie. Many patient with chronic respiratory disease are malnourished due to poor intake or hyper-metabolism) and elicit an overall impression of the way which the disorder affect patient lifestyle (ie. Ask patient to describe a typical day from walking in morning to going to bed at night. How does the disorder affect social interactions?). Initial Questions
  12. 12. • Smoking History  Does patient lives or works with people who smoke, does patient have a history of smoking [frequency, form (pipe, cigar, un/filtered cigarettes), duration, tar content of tobacco used, and has patient given up smoking?]. Initial Questions
  13. 13. What are the More Specific Questions Related to Respiratory Symptoms?? • Cough and sputum, Chest pain, Wheeze, Breathless, and Other symptoms. *mnemonic: Chronic Chest Will Behave Oddly.
  14. 14. Cough and Sputum • Cough  Questioning relates to nature & productivity of cough (Does the patient have a cough? If so, is it effective? Cough can also be affected by pain, weakness or drug. How long has the cough been present and when is it most noticeable? Has it recently changed in nature or become more persistent? Is cough productive? If affirmative what colour is the sputum and how much is expectorated each day?). • Sputum  Colour of suptum gives an insight into the nature of the disorder.
  15. 15. Sputum Indicates Green Staphylococcus aureus Mucopurulent/ purulent (Contain pus) Respiratory Infection Mucoid Airways Irritation Flecked with Black Usually Smokers Haemoptysis (Blood Stained Sputum) – Rupture of small Blood Vessels – Mucosal Ulceration – Carcinoma of Bronchus (L) – Pulmonary embolus (L) – Lung Contusion (L) White Frothy Sputum, sometimes Pink Pulmonary Oedema Thick Sputum Patient is dehydrated
  16. 16. Chest Pain • Vary in intensity and origin. • Give psychological support alongside with prescribed drug or physical management. • Question  Site and distribution + nature of pain. • Systems may precipitate pain  Cardiovascular system, pulmonary system, digestive system, and musculoskeletal system.
  17. 17. Common Cause of Chest Pain Region Example Elaboration on Example Cardiac Angina Pectoris Constricting pain commonly radiating to left arm and jaw. Cause by cardiac ischemia. Pericarditis Retrosternal pain often exacerbated by respiration. Pulmonary Pleuritic Sharp stabbing pain aggravated by deep breathing but not tender on palpation. May associate with pulmonary infection, pneumothorax or pulmonary embolism. Tracheitis Raw central chest pain aggravated by coughing. Digestive Oesophageal Reflux Retrosternal burning Worst when lying down and leaning forward Musculoskeletal Muscular Strain Dull ache around coastal margin Can be due to excessive coughing Rib Fracture Sharp localised pain worst on deep breathing and extremely tender on palpation
  18. 18. Wheeze • Air flow through narrowed airways  increase work of breathing. • Occur in presence of bronchospasm or with stridor due to foreign body inhalation. • Can be identify by both listening at the mouth and by auscultation. • Noisy breathing associate with retained secretions; True wheeze often musical. • If wheezing present  determine any precipitating factors such as dust and pollen (asthma). • Presence of both inspiratory and expiratory wheeze indicates severe airways narrowing such as cause by copious tenacious secretions.
  19. 19. Breathlessness • Patient personal exp  Dyspnoea *Must differentiate Tachypnoea, Hyperpnoea, Hyperventilation. • Question precipitating and easing factors, mode of onset, and progression  nature of breathlessness *severity of breathlessness  functional and exercise limitations. • Ask about nocturnal breathlessness (ie. How many pillows do you sleep with)  Orthopnoea and paroxysmal nocturnal dyspnoea. • Nocturnal breathlessness may occur in supine or slumped positioned  *reduction in functional residual capacity (abdominal contents elevating diaphragm and collapsing lung bases), Diaphragm fatigue  reduce gaseous exchange.
  20. 20. Orthopnoea • Poor functioning of left ventricle resulted in pooling of blood in pulmonary circuit. • Lying  ↑ venous return and redistribution of stored blood within the pulmonary vascular beds  ↑ pulmonary hypertension  oedema which interferes with gaseous exchange.
  21. 21. Paroxysmal Nocturnal Dyspnoea • Occur if patient with orthopnoea who usually sleeps propped up (numbers of pillows, incline sitting in ICUs & wards etc.) slides into a more recumbent position. • Patients who experience only Orthopnoea or Paroxysmal Nocturnal Dyspnoes caused by cardiovascular disorder may also have respiratory disorders.
  22. 22. Other Symptoms • Headaches, body weight, night sweats • Headaches in morning *may indicate CO₂ retention (↑ PaCO₂  cerebral vasodilation  raises the pressure of the CSF  Headaches) • Rapid reduction in body weight *without intention  associated with advance carcinoma • Night sweats  typical for pulmonary TB *Check: immunosuppressed? Advent new drug-resistant strains of the TB bacillus?
  23. 23. Objective Assessment • Physical examination of the patient. • Determine the degree of respiratory disorder and/or disorders of other systems affect normal functioning. • Steps: 1. Note drips, drains & % of any supplemental O₂. 2. Review charts at bed side (Temperature, HR & Rhythm, BP, peak flow & fluid balance)  Record current values and trend of parameters *Gives valuable insight on progression. • ↑ temperature = infection; Any instability of CV system affects physiotherapeutic intervention; Assessment of medication patient requires shows patient CV / Haemodynamic status requires support.
  24. 24. Positioning of Patient • Adequately undress & sitting at angle of 45⁰  However patient should be allowed to choose a more comfortable position. • Comprises observation, palpation & physical testing. • Begins with general observation  detailed examination commencing with lower extremities (Allows patient to get used to being touched on more acceptable areas before handling the more intimate areas).
  25. 25. General/Facial Observation • Observe facial expression before making contact (behaviour alters once they aware of being observe)  level of alertness, psychological state (degree of anxiety or distress). • Signs of central cyanosis (lips, oral mucosa & tongue) & pursed lip breathing. *If present verified the PaO₂ & SaO₂ (Patient present with anaemia  may not appear cyanosed in reduce O₂; Patient with polycythaemia  appear cyanosed with minimal reduction in O₂). • Pursed lips breathing keep floppy airways from closing but ↑ work of breathing.
  26. 26. Upper and Lower Extremities • Focused on assessment of CV and MS systems • CV  Skin colour, texture, temperature, presence of pulse and swelling. • Peripheral cyanosis, cooler extremities & absent/poor peripheral pulse  Partial Obstruction or Low Blood Pressure (atheroma/poor cardiac output). • Look for clubbing of toes & fingers (increase curvature & loss of angle of nail bed) [Sudden onset  associated with carcinoma; More insidious onset  associated with long term respiratory sepsis or cardiac disease]. • Observation and palpation of muscle bulk and tone should correlated with the level of activity.
  27. 27. Swelling Unilateral Trauma Palpation : Firm (proteinous of the exudate) Associate : Bruising Venous Obstruction (DVT) Bilateral Right Ventricular Failure Peripheral oedema associated with ascites, hepat omegaly and raised jugular venous pressure (JVP) Impairs kidney Function Hypoxaemia and hypercapnoea which impairs the kidney causing fluid retention.
  28. 28. Abdomen • Airways obstruction: Abdominal muscles are actively contracting during expiratory phase to force air out the narrowed airways  increase work of breathing and doesn’t results in enhance respiratory flow *Palpate abdomen confirms abdominal muscle activity. • Diaphragmatic weakness: Paradoxical abdominal movement. Accessory muscle ↑ thoracic size (inspiration d/t ↓ intrathoracic pressure, ↓ pressure diaphragm move upwards, abdominal walls fall inward). • Obese patient: enlarge abdomen offers resistance to downward movement of diaphragm reducing basal ventilation. • * Violent changes in pressure associated with frequent coughing may results in inguinal hernia.
  29. 29. Chest and Neck • Begin: General observation of chest and neck (overall shape, symmetry of thorax and respiratory movt). • Measurement of RR, depth and pattern should be made without patient knowledge. *Awareness may influence these 3 parameters • Positioning: Sitting  position of choice for palpating tenderness, expansion, auscultation and percussion. • Palpate for tenderness and chest movt (upper zone, middle (lingular) zones and Lower zones.
  30. 30. Respiratory Rate • Normal 12 - 18 breaths/min • > 40 breaths/min = Tachypnoea – Associate with ↑ work of breathing and may not result in reduce PaCo₂ • Reduce rate = Hypopnoea – Associate with ↑ PaCo₂
  31. 31. Breathing Pattern • Ratio of I:E = 1:2 • Deviation from the ratio is less efficient and leads to ↑ work of breathing & altered blood gases • Usually patients with airways obstruction is 1:3 or 1:4. • Also check for activity of accessory muscles of respiration. *Although improvement in ventilation at expense of ↑ breathing workload which associated with ↑ O₂ consumption.
  32. 32. Jugular Venous Pressure (JVP) • Estimated by looking at level of column of blood in jugular veins. • Bed end elevate 45⁰, patient’s neck veins may only visible above clavicle. * Elevation of venous pressure may distend these vessels up to the level of the jaw. • Measure in centimetres from the sternal angle. • Normal JVP is 3-4 cm; any reading above this measurement is abnormal
  33. 33. Raised JVP • A failing right ventricle *Right ventricle not emptying effectively. • Hypervolaemia (an increase in circulating fluid volume). • Generation of high pressure in the thorax on expiration *when there is obstruction to respiratory flow, high pressure generated on expiration compress soft veins wall and impede flow to the right ventricle, raising JVP.
  34. 34. Palpation of trachea • Lightly place the thumb & fingers on either side of trachea above suprasternal notch  Should be centrally positioned. • Shift from midline indicate: collapse, pneumothorax, lung tumour or a large pleural effusion. • Loss of lung volume causes a shift of trachea towards the side of collapse. • Pressure from pneumothorax, lung tumour etc forces trachea towards opposite side.
  35. 35. Level of Hydration • Place fingers in the axillae. • Axillae should be warm and moist; if dry this indicates dehydration. • Dehydration makes sputum clearance more difficult.
  36. 36. Hyperinflation of the Thorax • Cause by certain chronic respiratory disease (COPD or episodic respiratory disorder). • Physical changes can be observe and plapated via examination. • Category: – Elevation of the upper thorax and shoulder girdle making trachea length appear shorter. – Loss of bucket handle movement and ↑ sternal lift (Pump handle movement). – Tracheal tug (Downward action of diaphragm pulling on trachea via mediastinum). *Sharp downward movement of thyroid cartilage & indrawing of coastal margin on inspiration.
  37. 37. Chest Palpation • Apical – Facing patient, place finger tips firmly around base of the neck overlying the upper fibers of trapezius & thumbs on sternal end of clavicle. • Anterior Aspects of the Middle Zone – Facing patient, place fingertips in axillae and applying tension on the underlying skin, span thumbs towards midline. • Posterior aspects of the Lower Zone – Standing behind, place fingertips up towards axillae & apply tension on underlying skin, span thumbs towards spine. * Once hands are in position, ask patient take a deep breath, observe movement of thumbs away from midline to determine degree, quality and symmetry of movement.
  38. 38. Auscultation • Useful tools to measure outcomes of physiotherapy intervention. • Listens in 1 position and compare with sounds over the reciprocal position on opposite side. • Breath sounds heard on auscultation are either generated by turbulence in trachea and large airways, air flow in smaller airways are usually silent. • Air is a poor conductor of sound which results in attenuation or damping. • Emphysema (greater number of air spaces)  difficult to hear anything at all • Consolidation (no air)  sounds are transmitted over lung tissues.
  39. 39. Bronchial Obstruction Fluid or air in Pleural Cavity Explanation: Plug of sputum/bronchial carcinoma prevents breath sounds from being transmitted even over a patch of consolidation Explanation: Large volume of air reduce transmission of sound waves whereas fluid reflects fluid away from chest wall. (Pleural effusion / pneumothorax)
  40. 40. Types of Sound • Bronchial sounds = Sounds heard over the chest wall are close to those heard over the trachea. • Crackles = Short explosive sounds occur on pressure equalisation across either narrowed airways or collapse alveoli. (Heard during inspiration and expiration). • Wheeze = Occur in both inspiration and expiration; Present in bronchospasm, sputum, floppy airways & oedema; Polyphonic wheeze = Widespread of airflow obstruction; Monophonic wheeze = localised obstruction. • Pleural Rub = Sounds like boots crunching on snow, stronger on inspiration than expiration and is associated with pain.
  41. 41. Other Sounds • Vocal Resonance – Voice sounds may be heard through a stethoscope • Vocal Fremitus – Voice sounds may be felt by placing hand over the chest wall.
  42. 42. Percussion • Helps to localise lung disease & is useful for patient whose ventilatory effort is so poor that use of stethoscope is negated. • Place finger over intercostal space and tap it sharply with middle finger. • Similar areas of both sides are compared. • Resonant note = normal lung; Hyperresonant note = Large volume of air present over pneumothorax; Dull percussion note = Atelectatic, consolidated lung tissue or pleural effusion
  43. 43. Specific Test • To estimate exercise tolerance • May be perform in chronic stage of disorder • Ie: 6 minute walk test / shutter walk test. • Results from testing gives accurate reference point from which success of rehabilitation programme & progression of the disease process may be evaluated.
  44. 44. 6 Minute Walk Test (6MWT) • Measure the response to medical interventions in patients with moderate to severe heart or lung disease. • Performed indoors, along a long, flat, straight, enclosed corridor with a hard surface that is seldom traveled. If the weather is comfortable, the test may be performed outdoors. • Walking course length – 30m; Length of corridor should be mark every 3m
  45. 45. Equipment for 6MWT 1. Countdown timer (or stopwatch) 2. Mechanical lap counter 3. Two small cones to mark the turnaround points 4. A chair that can be easily moved along the walking course 5. Worksheets on a clipboard 6. A source of oxygen 7. Sphygmomanometer 8. Telephone 9. Automated electronic defibrillator
  46. 46. 6MWT Patient Preparation 1. Comfortable clothing should be worn. 2. Appropriate shoes for walking should be worn. 3. Patients should use their usual walking aids during the test (cane, walker, etc.). 4. The patient’s usual medical regimen should be continued. 5. A light meal is acceptable before early morning or early afternoon tests. 6. Patients should not have exercised vigorously within 2 hours of beginning the test.
  47. 47. Measurements of 6MWT 1. Repeat testing should be performed about the same time of day to minimize intraday variability. 2. A “warm-up” period before the test should not be performed. 3. The patient should sit at rest in a chair, located near the starting position, for at least 10 minutes before the teststarts. During this time, check for contraindications, measure pulse and blood pressure, and make sure that clothing and shoes are appropriate.
  48. 48. Instruction for 6MWT “The object of this test is to walk as far as possible for 6 minutes. You will walk back and forth in this hallway. Six minutes is a long time to walk, so you will be exerting yourself. You will probably get out of breath or become exhausted. You are permitted to slow down, to stop, and to rest as necessary. You may lean against the wall while resting, but resume walking as soon as you are able. You will be walking back and forth around the cones. You should pivot briskly around the cones and continue back the other way without hesitation. Now I’m going to show you. Please watch the way I turn without hesitation.” “Are you ready to do that? I am going to use this counter to keep track of the number of laps you complete. I will click it each time you turn around at this starting line. Remember that the object is to walk AS FAR AS POSSIBLE for 6 minutes, but don’t run or jog. Start now, or whenever you are ready.”
  49. 49. Interpretation of Assessment Findings • Individual findings should not be consider in isolation but view and evaluate in light all information gathered. • Construct a problem list and revised the order of priority. • Get agreement before objective setting to ensure patient compliance with treatment. • Realistic short and long term goal (Short term = Current clinical features; Long term = Activities of daily living).
  50. 50. Reference • Smith, M. and Ball, V. (1998) Cardiovascular respiratory physiotherapy. Reprint, New Delhi: Sanat Printers, 2005. • American Thoracic Society (2002) ‘ATS Statement: Guidelines for the Six-Minute Walk Test’, AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, 166, pp. 111-117 APTA [ONLINE] Available at: fet/sixminute.pdf (Accessed: 5 January 2011).