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Assessment of The Patient

Assessment of The Patient. 210a. Objectives. List The Elements of an Effective And Thorough Bedside Interview List The Factors That Influence Communication Positively And Negatively Define The Difference Between Objective And Subjective Data. Objectives.

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Assessment of The Patient

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  1. Assessment of The Patient 210a

  2. Objectives • List The Elements of an Effective And Thorough Bedside Interview • List The Factors That Influence Communication Positively And Negatively • Define The Difference Between Objective And Subjective Data

  3. Objectives • List The Causes of Cough, Sputum Production, Hemoptysis, Dyspnea, Chest Pain, Swelling of Feet And Ankles, Fever, Altered Mental Status, And Dizziness • Identify Normal And Abnormal Breathing Patterns

  4. Objectives • Identify Normal And Abnormal Breath Sounds • List The Normal Values of a CBC • List The Normal Values of a Chemistry Panel And The Causes of Deviations From The Normal Values

  5. Objectives • List The Common Normal Flora Found During Culture • List The Pathogens Found During Culture • List The Normal Values For an Arterial Blood Gas

  6. Objectives • List The Indications For Chest Radiography • List The Common Views And The Indications For Each • List The Normal Parts of an ECG Wave

  7. Objectives • List The Abnormalities of an ECG And Significance of Each • Explain The Need for Nutritional Assessment

  8. Chart Review • Demographic Data (name, address, next of kin, medical insurance info…) • Chief Complaint • History of Present Illness • Past Medical History

  9. Chart Review • Chief Complaint: • formally known as CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for a medical encounter. • The patient's initial comments to a physician, nurse, or other health care professional help form the differential diagnosis. • In some instances, the nature of a patient's chief complaint may determine whether or not services are covered by medical insurance • Open-ended questions are used in order to obtain the presenting complaint. • Other terms sometimes used include Reason for Encounter (RFE), Presenting Problem, Problem on admission and Reason for Presenting

  10. Chart Review • History of Present illness (HPI) • refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, abdominal pain). • SAMPLE history is an mnemonic acronym to remember key questions for a person's assessment • The SAMPLE history is usually taken along with vital signs. It is used for alert people, but often much of this information can also be obtained from the family of an unresponsive person. • Signs and Symptoms • Allergies • Medications • Past medical history • Last oral intake • Events leading up to the injury and/or illness

  11. Chart Review • Past Medical History: • is the total sum of a patient's health status prior to the presenting problem. Includes: • ifferent sources include different questions to be asked while conducting a PMH, but in general, they include the following: • General state of health: e.g. excellent, good, fair, poor. Note any significant change from previous state. • Past illnesses: e.g. cancer, heart disease, hypertension ,diabetes. • Hospitalizations: including all medical, surgical, and psychiatric hospitalizations. Note the date, reason, duration for the hospitalization. • Injuries, or accidents: note the type and date of injury.

  12. Chart Review • Past medical Hx: • Surgeries: note the type of procedure, date, hospital, surgeon, and any complications. • Current medications: note name, dosage, frequency of any medication, including any over-the-counter medications and herbal remedies. Note whether patient is taking the medications according to the prescribed instructions. • Allergies: note any environmental, food, or drug allergies, as well as the specific type of reaction, e.g. anaphylaxis, rash, itching. • Immunizations: take a careful record of all immunizations, including tetanus, diphtheria, pertussis, polio, Hepatitis B, measles, mumps, rubella, Haemophilusinfluenzae type B, influenza • Substance abuse: note any alcohol, tobacco, and illicit drug use, include type, amount, and duration, as well as any past treatment or drug rehabilitation.

  13. Chart Review • Past Medical Hx: • Diet: ask about everything the patient has eaten the day before and for the past week. Note the type of food consumed and do a nutritional status assessment. • Sleep: a useful mnemonic for sleep patterns is BEARS, for Bedtime problems (e.g. snoring, sleep apnea, or nightmares), Excessive daytime sleepiness, Awakenings at night, Regularity and duration of sleep, Snoring. • Alternative therapies: e.g. acupuncture, massage… • sexual history and any history of sexually transmitted diseases • . Birth history: details of labor and delivery of patient, admission to NICU, maternal fever, duration of rupture of membranes, Apgar scores (particularly import in first three months of life) Growth and development: plots of height, weight, and head circumference are standard content for pediatric records

  14. Chart Review • If possible, before every patient encounter, you should review the patients chart including: • History and physical • Pulmonologist consultation • Orders (verify your orders!!) • MAR • Labs • Diagnostics (Chest X-ray, PFT, V/Q scan…)

  15. Chart Review • In order to assess your patient fully and thoroughly you must first have a good idea of the patients chief complaint, admitting diagnosis and history • The goal is to correlate all the information you collect in the chart and from the patient to formulate an appropriate respiratory therapy plan or course of action (for you case studies, you will also need to formulate a overall plan, not just a RT plan)

  16. Chart Review • Family History: genetic factors, smoking in home… • Social And Environmental History: Work related illness, smoking/alcohol/drug use? • Review of Systems: This is found on the History and Physical, performed by every consulting MD and the primary care provider (PCP)

  17. Chart Review • Review of Systems: • A review of systems (also called a systems enquiry) is a technique used by health-care providers for eliciting a history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician). It can be particularly useful in identifying conditions that don't have precise diagnostic tests

  18. Chart Review • Review of systems: • Eyes • Head, Ears, Nose, Throat (HENT) • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Neurological • Pyschiatric • Hematologic • Immunological

  19. Patient Encounter • Before seeing your patient: • Know their name • Review their chart • Have your equipment ready (if needed) • Abide by any isolation requirement as necessary • Knock on door, introduce yourself as a student respiratory therapist state purpose of visit • Wash hands at door way • Ask patient to state their name • Put on gloves • Identify further by asking birth date, look at arm band to confirm

  20. Patient Encounter • Ensure patient is understanding of your purpose, ask questions, and answer patient • Continue assessment

  21. The Patient Interview • Purpose • Establish Rapport • Obtain Diagnostic Information • Monitor Changes in Patient Condition

  22. The Patient Interview • Guidelines • Give The Patient Your Complete Attention • Be Professional in Both Demeanor And Speech (address patient by Mr or Mrs) • Take into consideration cultural diversity

  23. The Patient Interview • Guidelines • Respect The Patient’s Beliefs, Attitudes, And Rights (some patients will be combative, confused, rude, angry…TREAT ALL PATIENTS AS CUSTOMERS) • Use a Friendly, Relaxed, Conversational Tone

  24. The Patient Interview • Guidelines • Obtain Information Through Asking Questions • Open-Ended Question • Closed, Specific Questions • Indirect Questions (Less Threatening) • Neutral Questions (Not Implying an Answer)

  25. The Patient Interview • What you should ask in a initial RT protocol interview: (RT focused) • Smoking history (pack years) • Hx of respiratory illness/disease • Cough/congestion hx • Use of Oxygen and Respiratory medications at home • Based on this interview, chart review and physical respiratory assessment, you may then come up with a treatment plan

  26. The Physical Examination • Vital Signs • Pulse (do Not rely on P.Ox) • Rate (normal 60-100) • Rhythm (strong but not bounding) • http://www.youtube.com/watch?v=36zbMwxoM6g

  27. The Physical Examiniation • Pulse: • Pulsusalternans is a physical finding with arterial pulse waveform showing alternating strong and weak beats.It is almost always indicative of left ventricular systolic impairment, and carries a poor prognosis. • In left ventricular dysfunction, the ejection fraction will decrease significantly, causing reduction in stroke volume, hence causing an increase in end-diastolic volume • There may initially be a tachycardia as a compensatory mechanism to try to keep the cardiac output constant. As a result, during the next cycle of systolic phase, the myocardial muscle will be stretched more than usual and as a result there will be an increase in myocardial contraction, This results, in turn, in a stronger systolic pulse

  28. The Physical Examiniation • Pulse: • http://www.youtube.com/watch?v=jTsjCZ9QxW8 • abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10mmHg or 10torr. When the drop is more than 10mmHg, it is referred to as pulsusparadoxus. That is, pulsusparadoxus has nothing to do with pulse rate or heart rate. The normal variation of blood pressure during breathing/respiration is a decline in blood pressure during inhalation/inspiration and an increase during exhalation/expiration. Pulsusparadoxus is a sign that is indicative of several conditions including cardiac tamponade, pericarditis, chronic sleep apnea, croup, and obstructive lung disease

  29. The Physical Examination • Bounding pulse: • normal under heavy exercise, pregnancy, alcohol consumption, or high anxiety.[ • It is common for people over the age of 60 to develop signs of this due to an overall increase in the systolic pressure from hardening arteries (Atherosclerosis). • A bounding pulse is also often associated with high blood pressure and large stroke volume, and HYPOXEMIA

  30. The Physical Examination • Weak/Thready Pulse: • Possible hypotension, failing heart, low heart rate • Besides the pulse, the rate is also important, note Tachycardia vs. Bradycardia. If patient is on a ECG monitor not presence of arrhythmias: • PVC • A-fib/A-flutter • VT/VF • Sinus rhythm vs. Junctional • Blocks…

  31. The Physical Examination • Vital Signs • Respiration • Rate (normal is 12-18) • Breathing Pattern (Accessory muscle use?)

  32. Heart Rate/Rhythm Cardiac monitors used in Telemetry floors, ER, ICU

  33. The Physical Examination • Breathing should be a quiet process, so when it is obvious/noticeable, it typically means distress. • Note presence of accessory muscle use, belly breathing, tripod breathing, grunting, diaphoresis, tachypnea/bradypnea, hyperventilation, Biots, Kussmauls, Cheyne Stokes… • Assess by placing hand on shoulder/upper chest • http://www.medicalvideos.us/play.php?vid=260

  34. The Physical Examination • Increased rate: • Metabolic acidosis compensation • Decreased tidal volume/decreased VA (increased deadspace, pulmonary emboli, edema, airtrapping…) • Increased VO2 • Anxiety/Pain/Fear • Fever/increased metabolic demand • Neurological impairment • Increased heart rate • Exertion • Medication (stimulants) • *Tx if indicated/sedatives? Fix underlying cause

  35. The Physical Examination • Decreased Rate: • Metabolic Alkalosis compensation • Increased tidal volume • Hypothermia • Sedatives • Sleeping • Neurological impairment • *We must ensure patient with decreased rate has a adequate minute volume/VA, to ensure proper acid/base balance. • Possible assistance in ventilation required

  36. Apnea Monitor Common with post surgical patients, risk of SIDS and OSA patients

  37. The Physical Examination • Blood Pressure (normal 90-130/40-60) • Hypertensive (possible stroke, stress, diabetes, hypervolemia, CAD, COPD) • Hypotensive (shock, dehydration, hypovolemia, sepsis, medications) • Manual/automatic or continuous with A-line • Temperature (36-38 Celsius) • Hyperthermia (seizures, increased VO2…) • Hypothermia • (thermometer, temporal scan)

  38. Blood Pressure/ sphygmomanometer composed of an inflatable cuff to restrict blood flow, and a mercury or mechanical manometer to measure the pressure. It is always used in conjunction with a means to determine at what pressure blood flow is just starting, and at what pressure it is unimpeded. Manual sphygmomanometers are used in conjunction with a stethoscope.

  39. Physical Examination • Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperatures are sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability or death. • The most common causes are heat stroke and adverse reactions to drugs. Heat stroke is an acute condition of hyperthermia that is caused by prolonged exposure to excessive heat or heat and humidity. The heat-regulating mechanisms of the body eventually become overwhelmed and unable to effectively deal with the heat, causing the body temperature to climb uncontrollably. Hyperthermia is a relatively rare side effect of many drugs, particularly those that affect the central nervous system. Malignant hyperthermia is a rare complication of some types of general anesthesia.

  40. General • Level of Consciousness • http://www.youtube.com/watch?v=aH0SsX51bd0

  41. Consciousness • Consciousness is defined as the state of being aware of physical events or mental concepts. Conscious patients are awake and responsive to their surroundings • The level of consciousness has been described as the degree of arousal and awareness. A manifestation of altered consciousness implies an underlying brain dysfunction. Its onset may be sudden, for example following an acute head injury, or it may occur more gradually, such as in hypoglycaemia.

  42. Consciousness • Causes of altered consciousness • A range of situations can lead to altered consciousness. These include: profound hypoxemia; hypercapnia; cerebral hypoperfusion; stroke; convulsions; hypoglycemia; recent administration of sedatives or analgesic drugs; drug overdose; subarachnoid hemorrhage; and alcohol intoxication

  43. LOC • Level of consciousness • It is not possible to directly assess the level of consciousness - it can only be assessed by observing the patient’s behavioural response to different stimuli. • During the initial rapid assessment of the critically ill patient, it is helpful to use the AVPU scale, with an examination of the pupils; the GCS should be used in the full assessment

  44. LOC • The AVPU scale is a quick and easy method to assess level of consciousness. It is ideal in the initial rapid ABCDE assessment: • Alert; • Responds to voice; • Responds to pain; • Unconscious

  45. LOC • Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and 15 (most awake/alert)

  46. LOC • GCS • Individual elements as well as the sum of the score are important. • Generally, brain injury is classified as: • Severe, with GCS ≤ 8 • Moderate, GCS 9 - 12 • Minor, GCS ≥ 13. • Tracheal intubation and severe facial/eye swelling or damage make it impossible to test the verbal and eye responses. In these circumstances, the score is given as 1 with a modifier attached

  47. LOC terms • Awake/Alert • Awake/confused • Confused/combative • Stupordous • Lethargic • Obtunded • Comatose

  48. Skin Appearance • Skin • Color – Normal, Pale (shock), Flushed Cyanotic • Warm, Cold • Dry, Diaphoresis (sweating)

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