CARDIORESPIRATORY ASSESSMENT

MEDICAL CHART READING:

Name, Age, Sex H\O Present Illness Past Medical History Past Surgical History Drug History Social/Occupational History Further Queries For Subjective Assessment Investigation (same as Performa)

BED CHART READING

Vital Signs Temperature >37.5? Source of temperature PR >100 tachycardia & <60 Bradycardia? Cause Tachy? Septic Brady? Medication BP varies with age, fitness, HT SpO >95% normal unless respiratory impairment Hb -- <8 (careful while mobilizing the pt) Other Readings Fluid Balance-Important Post Op, CRF, CCF & MI Peak Flow Readings Pain Scales- Post Op Cases Medications

SUBJECTIVE ASSESSMENT
What is the main problem? What brought them to hospital? Cough - how much, when, triggering factor, productive/non-productive? SOB/Dyspnoea -? Cause duration, aggravating factors Sputum - colour, quantity, quality Pain - area, type, pain scale, relate to present condition Ex Tolerance - distance, flat surface, stairs Smoking History - no. of cigarettes/no. of years Sleeping Position/Recovering Position

 Home Program - airway clearance techniques, peak flows, medications, walking program.

OBJECTIVE ASSESSMENT
OBSERVATION Pts appearance/posture/position in bed Effect on SOB while moving in bed/talking Breathing Pattern - RR, resp ms use, accessory ms use, purse lip breathing Colour/Cyanosis Signs of distress Audible Wheeze Chest Shape - kyphosis, kyphoscoliosis, pectus excavatum, pectus carinatum, barrel chest

Calf check - redness, swelling Incision - length, pus, infection Sputum Lines, Tubes, Drains

PALPATION

Position of Trachea

Chest Excursion

Middle lobe & lingula motion

Upper lobe motion

Lower lobe motion

Hand Placement - below clavicle bilaterally for Upper Lobe Laterally below axilla for Middle Lobe Laterally over 7-10 ribs for Lower Lobe Note symmetrical chest wall movement Also note while hand placement - Temperature, Sweating, Subcutaneous Emphysema

Percussion

With the middle finger over the intercostals spaces. Compare bilaterally -Hyper resonant - air/hyperinflation/pneumothorax -Dull - fluid/soft tissue/consolidation

Vocal Fremitus

Hand placement same as chest excursion. Compare bilaterally --Ask pt to say k or 99 --Note sound transmission under palm -Decrease transmission = air/emphysema -Increase transmission = consolidation, fluid

Calf Check Temperature --Remove DVT stockings --Check for increase in temp bilat wit dorsum of hands Tenderness --Squeeze the calf gently from proximal to distal wit both the hands --If +ve immediately inform the Doctor or sister --Do not move the lower extremity and make pt to stand and walk. Auscultation

A Chest

B Back

Instructions --Explain what you are going to do --Take slightly deeper breaths than normal &breath in & out through your mouth slowly and gently --Request the pt not to talk while auscultation --Ask the pt to turn his/her head away If pt becomes SOB during auscultation --Stop auscultation --Position pt --Commence relaxed deep breathing Try not to auscultate for more than 2 breaths per area.

REASSESSMENT 1) Response to technique 2) Tolerance for treatment 3) Change of objective signs 4) Re-auscultate the involved lung segment 5) Question pt how they feel