Download RET 1024 Introduction to Respiratory Therapy

RET 1024
Introduction to Respiratory Therapy
Module 4.1
Bedside Assessment of the Patient
— Patient Interview, Medical History, Sensorium
and Vital Signs
Beside Assessment of the Patient
RTs are playing an increasing role in the
clinical decision-making process when it
comes to initiating, adjusting, or discontinuing
respiratory therapy.
Bedside Assessment of the Patient
As never before, RTs need to develop
competent beside assessment skills in order
gather and interpret relevant patient data
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
Bedside Assessment of the Patient
Two key sources of patient data
 Medical History
 Physical Examination
Bedside Assessment of the Patient
Medical History & Physical Examination
Data gathered initially by the interview and physical
examination help identify the need for subsequent
diagnostic tests
Bedside Assessment of the Patient
Interviewing & Taking a Medical History
1. Provides patient perspective
 Subjective information
2. Establishes rapport between clinician and patient
 Facilitates the sharing of information and future evaluation and
treatment plans
3. Obtains essential diagnostic information
 Objective information
4. Monitors changes in the patient’s symptoms and
response to therapy
Bedside Assessment of the Patient
Interview skills are an art form that
takes time and experience to develop
Bedside Assessment of the Patient
Patient interviews requires …
 A genuine concern for others
“People don’t care how much you know until they know
how much you care.”
Theodore Roosevelt
 Empathy
 The ability to view the world from the patient’s
perspective; recognition of the patient’s feelings without
criticism - feeling with the patient
Bedside Assessment of the Patient
Patient interviews requires …
 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
Bedside Assessment of the Patient
Structure and Technique for Interviewing
 Introduction
 Address patient by his or her surname, using Mr., Mrs.,
Senor, Senora.
 Introduce self and explain 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
Bedside Assessment of the Patient
Structure and Technique for Interviewing
 To Begin The 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
Bedside Assessment of the Patient
Structure and Technique for Interviewing
 Questions and statements used in a
conversational interview
 Closed Questions; focus on specific information, provide
clarification
 “When did your cough start?”
 Open-ended questions; encourages patients to describe
events and priorities as they see them, helping bring out
concerns and attitudes and promote understanding
 “What brought you to the hospital” or “What happened
next?”
Bedside Assessment of the Patient
Structure and Technique for Interviewing
 Questions and statements used in a
conversational interview
 Indirect questions; less threatening because they sound
like statements
 “If I understand you correctly, it is harder for you to breathe
now than it was before your treatment.”
Bedside Assessment of the Patient
Structure and Technique for Interviewing
 Questions and statements used in a
conversational interview
 Neutral questions; a subset of open-ended questions.
They allow respondents to decide upon answers without
overt direction or pressure from questioners
 Open Ended: “What happened next?”
 Closed: “Would you say that you expectorated a
teaspoon, tablespoon, or half a cup?” (gives the patient a
choice of responses while focusing on the type of
information needed)
Bedside Assessment of the Patient
Structure and Technique for Interviewing
 Questions and statements used in a
conversational interview
 Reflecting (echoing); repeating words, thoughts, or
feelings that the patient just stated for purposes of
clarifying or stimulating elaboration from the patient
 Facilitating phrases; e.g., “yes” or “I see” used with eye
contact and perhaps nodding of the head, show interest
and encourage patients to continue their story
Bedside Assessment of the Patient
Structure and Technique for Interviewing
 Questions and statements used in a
conversational interview
 Communicating empathy (support); shows your concern
for the patient as a human being
 “That must have been very difficult for you.”
Bedside Assessment of the Patient
Structure and Technique for Interviewing
 Alternate Sources for a Patient History
 Various factors affect the patient’s ability or willingness to
provide an accurate history, e.g., age, alterations in level
of consciousness, language, cultural barriers, emotional
state, acuteness of the disease, etc.
Bedside Assessment of the Patient
Structure and Technique for Interviewing
 Alternate Sources for a Patient History
 In such cases, family members, friends, work associates,
previous physicians, and past medical records often
provide a more accurate picture of the history and
progression of symptoms
Bedside Assessment of the Patient
Medical History
Because dysfunctions of the respiratory system are
often manifestations of other systemic disease
processes, and because changes in pulmonary
functions may affect other body systems, a
cardiopulmonary assessment cannot be limited to the
chest; a comprehensive evaluation of the patient’s
entire health status is essential
Bedside Assessment of the Patient
Medical History
 Demographic data
 Name, Date of birth, Race, Religion, Occupation, Etc.
 Date and source of history and estimation of the
reliability of the historian
 Patient’s condition at time of history
Bedside Assessment of the Patient
Medical History
 Chief complaint
 Reason for seeking treatment (admitting diagnosis)
 History of present illness
 Chronological description of each symptom





Onset
Frequency
Location
Severity
Etc.
Bedside Assessment of the Patient
Medical History
 Past medical history





Childhood diseases
Hospitalization, surgeries, injuries, accidents
Major illness
Allergies
Medications
 Family history
 Familial disease history
 Marital history
Bedside Assessment of the Patient
Medical History
 Social / environmental history
 Alcohol and cigarette consumption
 Occupational links to disease
 Gas / Chemical fumes
 Dusts
 Living arrangements
 Religious and social activities
 Recent travel or other event that might impact health
Bedside Assessment of the Patient
Medical History
 Review of systems
 Head-to-toe review of all body systems (done by a
physician, located in “History & Physical section of chart)








Eyes, ears, nose, mouth, throat
Skin
Cardiorespiratory system
Digestive system
Genitourinary system
Endocrine system
Nervous system
… and more
Bedside Assessment of the Patient
Physical Examination
 Acute problem
 Abbreviated examination
 Stable
 More complex assessment
Bedside Assessment of the Patient
Physical Examination
 General Appearance
 Facial expression






Pain
Anxiety
Alertness
Mood
Mental capacity
Respiratory distress
Bedside Assessment of the Patient
Physical Examination
 General Appearance
 Diaphoresis (sweating)





Fever
Pain
Severe stress
Increased metabolism
Acute anxiety
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
Bedside Assessment of the Patient
Physical Examination
 General Appearance
 Personal hygiene
 Duration and impact of illness on daily activities
 May indicated psychiatric disorder
 Nutritional status
 Well nourished or emaciated
Bedside Assessment of the Patient
Physical Examination
 Levels of Consciousness (common clinical terms for the
varying levels of depressed consciousness)
 Conscious (alertness)
 Evaluate sensorium
 Oriented to Person, Place, Time (“oriented x 3”)
Bedside Assessment of the Patient
Physical Examination
 Levels of Consciousness (common clinical terms for the
varying levels of depressed consciousness)
 May occur with:
 Poor cerebral blood flow or poorly oxygenated blood
perfusing the brain
(restless, confused, disoriented)
 Chronic degenerative brain disorders
 Medication side effects
 Drug overdose
Bedside Assessment of the Patient
Physical Examination
 Levels of Consciousness (common clinical terms for the
varying levels of depressed consciousness)
 Confused




Decrease of consciousness
Slow mental responses
Dulled perception
Incoherent thoughts
 Delirious
 Hallucinations
 Easily agitated
 Irritable
Bedside Assessment of the Patient
Physical Examination
 Levels of Consciousness (common clinical terms for the
varying levels of depressed consciousness)
 Lethargic
 Sleepy
 Arouses easily
 Responds appropriately when aroused
 Obtunded
 Awakens only with difficulty
 Responds appropriately when aroused
Bedside Assessment of the Patient
Physical Examination
 Levels of Consciousness (common clinical terms for the
varying levels of depressed consciousness)
 Stuporous




Does not awaken completely
Decreased physical and mental activity
Responds to pain and deep tendon reflexes
Responds slowly to verbal stimuli
Bedside Assessment of the Patient
Physical Examination
 Levels of Consciousness (common clinical terms for the
varying levels of depressed consciousness)
 Comatose




Unconscious
Does not respond to stimuli
Does not move voluntarily
Loss of reflexes with deep or prolonged coma
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
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 patient’s 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
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”
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Body Temperature
 Hyperthermia – body temperature
 AKA: “fever” or “febrile”
 Increases metabolic rate ( oxygen
consumption,  CO2 production), accompanied
by  heart rate and  ventilation to maintain
homeostasis
NOTE: This condition may eventually lead
to respiratory failure
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Body Temperature
 Hypothermia – body temperature
 Excessive heat loss (e.g., prolonged exposure to
cold)
 Inadequate heat production
 Impaired hypothalamic thermoregulation (e.g.,
head injury, stroke)
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Body Temperature
 Hypothermia – body temperature








Decreased pulse and respiratory rate
Patient indicates coldness
Shivering (generates heat)
Pale or bluish cool, waxy skin
Hypotension
Disorientation
Drowsy or unresponsive
Coma
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Body Temperature
 Measured
 Rectum(reflects core temperature)
 Ear – tympanic membrane (reflects core temperature)
 Oral (most common), about 1 F lower than rectal
temp
 Axilla (1 - 2 F lower than oral temp)
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
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
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)
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Pulse Rate
 Bradycardia; < 60 beats/min
 Physically fit athletes
 Hypothermia
 Head injury
 Side effects of medication
 With certain cardiac arrhythmias
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Pulse Rate
 Tachycardia; > 100 beats/min
 Exercise
 Fear, anxiety
 Low blood pressure (hypotension)
 Anemia
 Dehydration
 Fever
  Arterial blood oxygen (hypoxemia)
 Certain medications
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
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
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Pulse Rate
 Strength
 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
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Pulse Rate
 Pulsus paradoxus; pulse decreases markedly in
strength during inspiration and returns to normal
during exhalation – common among patients
experiencing severe asthmatic episodes
 Pulsus alternans; strength of patient’s pulse varies
every other beat while the rhythm remains regular
(left-sided heart failure)
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)
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 patient’s artery
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Respiratory Rate
 Tachypnea; abnormally high respiratory rate
 Exertion
 Fever
 Arterial hypoxemia
 Metabolic acidosis
 Anxiety
 Pain
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Respiratory Rate
 Bradypnea; slow respiratory rate
 Head injuries
 Hypothermia
 Side effect of certain medications (narcotics)
 Severe myocardial infarction
 Drug overdose
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Respiratory Pattern
 Apnea – no breathing
 Asthmatic breathing – prolonged exhalation
 Kussmaul’s – deep and fast (associated with diabetic
acidosis)
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Respiratory Pattern
 Cheyne-Stokes – increases and decreases in depth
and rate with periods of apnea (low cardiac output as
in CHF)
 Biot’s – similar to Cheyne-Stokes except tidal
volumes are identical in depth (increased intracranial
pressure)
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Respiratory Rate
 Apneustic – sustained inspiratory effort (damage to
pons associated with head trauma, severe brain
hypoxemia, lack of blood flow to brain)
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; 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
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 > 140 or diastolic > 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
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 (ringing in the ears)
 Light-headedness, confusion
 Easy fatigability
 Cardiac palpitations
 Blurred vision
 Renal failure (uremaia), CHF, cerebral hemorrhage,
leading to stroke
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Blood Pressure (BP)
 Recorded as systolic / diastolic (e.g., 120/80 mm Hg)
 Hypertension
 Hypertensive crisis; an acute, severe elevation of BP
causing neurological, cardiac, and renal failure
 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).
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Blood Pressure (BP)
 Hypotension; BP < 90/60 mm Hg
 Blood pressure is not adequate for normal perfusion
and oxygenation of vital organs
 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
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
Bedside Assessment of the Patient
Physical Examination
 Measuring BP
 Commonly measured
using auscultation
 Sphygmomanometer
and stethoscope
 BP cuffs come in
different sizes
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Pulse oximetry
 SpO2
Bedside Assessment of the Patient
Physical Examination
 Vital Signs
 Pulse oximetry
 Establishes an immediate baseline SpO2 value
 Excellent monitor by which to assess the patient’s
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
Bedside Assessment of the Patient
SpO2 and PaO2 Relationship for the Adult and Newborn
Adult
Oxygen Status
Newborn
SpO2
PaO2
SpO2
PaO2
Normal
95-99%
75-100
91-96%
60-80
Mild hypoxemia
91-94%
60-75
88-90%
55-60
Moderate hypoxemia
86-90%
50-60
85-89%
50-58
Severe hypoxemia
<85%
<50
<85%
<50