From Pupils to Pedal Pulses: Physical assessment of the palliative patient

1. From Pupils to Pedal Pulses: Physical assessment of the palliative patient Cheryl Talbot NP-Adult LHSC-University Hospital 2007 CAPCE Grad

2. Focus of Assessment • Knowledge of pre-existing diseases and presenting symptoms • Verify that a pre-existing condition is responsible for the patient’s symptoms • Does a new acute condition need further evaluation or management? Krause, RS (2011)

3. Purpose of the Assessment • Explore the potential problems and adverse effects of the abnormalities that may be impacting the person’s quality of life • What’s troubling you now? • What symptoms might we expect you to develop?

4. Getting Organized

5. Considerations • Setting • Warm, private, quiet • Equipment • Stethoscope • Possibly BP cuff, SaO2 monitor • Flashlight • Mouthcare items • Approach • Calm, methodical

6. Assessment Techniques • Inspection • Look before you touch • Compare right and left sides of the body • Palpation • Slow and systematic • Warm your hands! • Light palpation first • Known tender areas last

7. Techniques cont’d • Percussion • Chest and abdominal assessment • Resonant, hyperresonant, tympanic, dull, flat • Auscultation • Listening with a REAL stethoscope • Chest, abdomen, blood vessels

8. Let’s get started!

9. All in the Eye of the Beholder • Physical appearance • ? Appears stated age • Level of consciousness • Skin colour • Facial features, symmetry • Body structure • Nutrition (e.g.) temporal wasting • Symmetry • Positioning

10. Survey cont’d • Mobility • Gait (if applicable) • Range of motion • Behaviour • Facial expression within cultural norms • Mood & affect • Speech • Dress & personal hygiene

11. Survey cont’d • Weight • Compare with previously known weight if possible • Intentional changes? • VS monitoring (if appropriate) • What are you going to do with the information?

12. Head & shoulders, knees and toes…

13. Judge a [body] by its cover… • Colour • Jaundice, pallor, cyanosis • Temperature, moisture • Turgor • Evidence of pruritis? • Lymphorrhea • In edematous limbs • Lesions, decubiti • Bruising • Gout

14. He may be the Head of the family, but… • Symmetry • Enlarged lymph nodes or thyroid • Parotitis?

15. Eyes & Nose • Conjunctiva • Sclera • Lids: incomplete closure, ptosis, ectropion, entropion • Pupils: equal, round, reactive to light (accommodation) • Presence of NG tube/oxygen per nasal prongs • Evidence of epistaxis

16. Say Ahhhh Xerostomia

17. Wider, now… Oral candidiasis a.k.a. Thrush

18. Take a deep breath in… • Inspect • Rate/rhythm • Accessory muscle use • Rattle ‘n’ hum • Palpate, if indicated • Usually for tenderness

19. And again… • Percuss, if indicated • Auscultate • Assess normal breath sounds • Adventitious sounds (crackles, wheezes) • Tongue obstruction (try jaw thrust)

20. Cardiovascular system • Rate/rhythm • Any extra heart sounds? • Pacemaker vs. defibrillator? • Need to know if defibrillator needs to be turned off

21. It’s not fat, it’s my darned ascites! • Inspection • Ascites • Foley • Any other tubes? (Risk of erosion from rectal tubes) • Auscultation • Hyperactive or hypoactive bowel sounds

22. Abdominal assessment cont’d • Percussion • Hyperresonance if gaseous distension • Dull over distended bladder • Palpation • Light, then deep, if indicated • Muscle guarding, tenderness, rebound tenderness • Masses • Normally some mild tenderness LLQ

23. Extremities • Positioning (esp. with hemiparesis) • Tremors • Myoclonus • Edema (Unilateral/bilateral/anasarca) • Mottling (vs. modeling!) • Palpate temperature • Pulses • Capillary refill

24. Pulling the pieces together:An example

25. History • History of prev. abdominal surgeries/cancer, etc. • Nausea & vomiting • Abdominal visceral pain • History of infrequent BMs • Absence of flatus

26. Physical Findings • Lethargic • Dry oral membranes, fecal halitosis • Tachycardic, hypotensive • Shallow breathing because diaphragm is elevated by abdominal distension • Distended abdomen • High-pitched or absent bowel sounds • Tympanic bowel sounds when percussed

27. Bowel Obstruction

28. The Last Hours

29. Signs and Symptoms • Rapidly progressing weakness & fatigue • Decreased or fluctuating LOC • Terminal delirium/agitation (family may interpret as pain) • Decreased or absent blinking → dry conjunctiva

30. Signs and Symptoms cont’d • Decreased oral intake and urine output (IV fluids do not reverse this) • Dry membranes • Dysphagia and loss of gag reflex • Mouth-breathing • Jaw falls posteriorly → narrowed airway → more difficulty clearing secretions

31. Signs and Symptoms cont’d • Secretion accumulation leading to resp. rattle • Changes in resp pattern/frequency/tidal volume • Apneic periods • Cheyne-Stokes • May moan with each exhalation • Accessory muscle use

32. Signs and Symptoms cont’d • Cardiovascular changes • Decreased peripheral perfusion • Tachycardia • Hypotension • Peripheral cooling • Peripheral and/or central cyanosis • Mottling • Venous blood pooling along dependant skin surfaces

33. Our Role as CAPCE Grads • Assess • Document • Communicate • Intervene • Evaluate

34. Consider the burden associated with potential treatments before proposing them

35. With acknowledgement and appreciation to:Cheryl Talbot RN, Msc(N), CHPCN(C), TCNP2007 CAPCE Graduate, London, Ontario, CanadaPermission granted for use in CAPCE Program (March 29, 2012)