Respiratory Assessment process and analysis

Cardiorespiratory assessment

1. CARDIORESPIRATORY ASSESSMENT 1
Respiratory Assessment

2. CARDIORESPIRATORY ASSESSMENT 2
PERSONAL DETAILS:
Name :
Age :
Gender :
Weight :
Life style :
Occupation :
Residence :
Ref. by :
Provisional diagnosis:

3. Chief complain :
Investigation:
Blood reports
Chest X-rays
PFT
ABG analysis
ECG
Sputum
CT scan
Bronchoscopy
CARDIORESPIRATORY ASSESSMENT 3

4. CARDIORESPIRATORY ASSESSMENT 4
HISTORY:
a)H/O presenting condition:
i.e. patient’s current problems, including relevant
information from medical notes
b) Previous medical history:
i.e. entire list of medical & surgical problems that the
patient has had in past
written in disease specific grouping or chronological
account

5. c) Family history:
List of any major disease suffered by members of
immediate family
d) Social history:
level of support available at home & to gain idea of
patient’s expected contribution to household
duties
e) H/O smoking & alcohol use:
no. of pack yrs may be calculated as relative risk of
COPD. i.e. (average no. of packs/day) (no. of yrs smoked)
f) Drug List:
List of patient’s current medication ( with dosage)
Drug allergies should also be noted
CARDIORESPIRATORY ASSESSMENT 5

6. CARDIORESPIRATORY ASSESSMENT 6
SUBJECTIVE ASSESSMENT:
Based on an interview with patient
Starts with open ended questions: what is the main problem?
what troubles you most?
5 main symptoms of respiratory diseases:
• Breathlessness
• Cough
• Sputum & Hemoptysis
• Wheeze
• Chest pain

7. CARDIORESPIRATORY ASSESSMENT 7
BREATHLESSNESS ( DYSPNOEA ) :
Subjective awareness of an increased WOB
Major symptom of cardiac & respi. Dzs.
Scales for assessment:
NYHA grading
Borg’s scale ( RPE )
ATS dyspnoea scale
VAS scale

8. NYHA Grading
I. No symptoms with ordinary activity, breathlessness only occurs with
severe exertion. e.g. running uphill, fast bicycling
II. Symptoms with ordinary activity. e.g. walking upstairs, making beds,
carrying large amounts of shopping
III.Symptoms with mild exertion. E.g. bathing, showering, dressing
IV. Symptoms at rest
CARDIORESPIRATORY ASSESSMENT 8

9. ATS
Grade
1(None)Not troubled by shortness of breath on level or uphill
2(Mild)Troubled by shortness of breath on level or uphill
3(Mod)Walks slower than person of same age
4(Severe)Stops after walking 100 yd
5(Very severe)Breathlessness at rest

10. CARDIORESPIRATORY ASSESSMENT 10
Patterns of Dyspnea:
• Orthopnea
• PND
• Platypnea
• Trepopnea
• Functional dyspnea

11. CARDIORESPIRATORY ASSESSMENT 11
COUGH:
Imp. features are its effectiveness & whether it is productive or dry
Severity : range from occasional disturbance to continual
trouble
A loud - barking cough : laryngeal or tracheal dzs
Recurrent cough after eating : aspiration
Ch. productive cough everyday : ch.bronchitis,
bronchiectasis
Persistent dry cough : ILD

12. Nocturnal cough : in children/young adults - asthma
in older pts – cardiac failure
Drugs – e.g. beta blockers & some anti hypertensives – ch.
Cough
Post-op. strength & effectiveness of cough is imp. to assess

13. Grey-chronic bronchitis
Black-smoke inhalation
Red-hemoptysis
Yellow-Lung Abscess(pus)
Pink-pulmonary odema
Red current jelly-klebsiella infection
Green-pseudomonas infection
White-mucoid-Asthma
Slightly discolored(pus)-cystic fibrosis
Purple-neoplasm
CARDIORESPIRATORY ASSESSMENT 13

14. CARDIORESPIRATORY ASSESSMENT 14
Odour signifies infection
Offensive odour – anerobic organism, e.g. lung
abscess, aspiration pneumonia
Sweet smell- Diabetic ketoacidosis

15. SPUTUM & HEMOPTYSIS:
Colour, consistency & quantity should be
determined
It clarifies diagnosis & severity of disease
GRADINGS for sputum by Miller ( 1963 ):
M1 : mucoid with no suspicion of pus
M2 : predomi. mucoid, suspicion of pus
P1 : 1/3 purulent, 2/3 mucoid
P2 : 2/3 purulent, 1/3 mucoid
P3 : > 2/3 purulent

16. CARDIORESPIRATORY ASSESSMENT 16
Hemoptysis: presence of blood in sputum
Range from slight streaking to frank blood (life threatening)
Frank bld requires bronchial a. embolisation or surgery
Isolated hemoptysis – 1st sign of bronchogenic carcinoma ( CXR
normal)
Recurrent hemoptysis – ch. Infective lung dzs, e.g.
bronchiectasis, TB, fungal infection

17. CARDIORESPIRATORY ASSESSMENT 17
WHEEZE:
Whistling or musical sound produced by turbulent
airflow through narrowed airways
Sometimes stridor is mistakenly called wheeze
Diff. between two:
stridor wheeze
Inspiratory expiratory
Upperairway obstruction lower airway obstruction
Cause : foreign body asthma, COPD

18. CARDIORESPIRATORY ASSESSMENT 18
CHEST PAIN:
Definitive cause can’t be fully established without
diagnostic medical tests, but origin can be determined
by carefull history taking
•Pleuritic:
Inflammation of parietal pleura
Severe sharp, stabbing pain, worse on inspiration
Not produced by palpation

19. CARDIORESPIRATORY ASSESSMENT 19
•Tracheitis:
Constant burning pain in centre of chest
Aggravated by breathing
•Musculoskeletal (chest wall) pain:
Originate from muscles, bones, joints or nerves of
thoracic cage
Well localised & aggravated by chest or arm movts
Palpation will reproduce pain

20. CARDIORESPIRATORY ASSESSMENT 20
•Angina pectoris:
Ischemia – dull, central, retrosternal gripping or
band like sensation, may radiate to arm, neck, jaw
•Pericarditis:
Pain similar to angina or pleurisy
Sitting up & leaning forward or lying on right side
relieves pain
Pain assessment : VAS scale

21. CARDIORESPIRATORY ASSESSMENT 21
Functional ability:
Inquiry abt his ADL
FIM scale
QOL:
Imp. to measure the impact of disability on pt &
of response to treatment
SF – 36

22. CARDIORESPIRATORY ASSESSMENT 22
OBJECTIVE ASSESSMENT:
General observation:
Is pt breathless?
Is pt comfortable?
Is pt on supplemental O2? If so, how much?
In ICU pt see level of ventilatory support:
Mode & route of ventilation
Level of CV support including drugs to control
BP & C.O., pacemakers & other mechanical
devices

23. CARDIORESPIRATORY ASSESSMENT 23
Level of consciousness should also be noted
It is measured by GCS
Reduced consciousness – risk of aspiration &
retention of secretions
See for presence or absence of ryle’s tube, IV line,
CVP line etc
Signs of respi distress: facial grimace, nasal flaring
etc.
Use of accessory muscles:

24. CARDIORESPIRATORY ASSESSMENT 24
Body built:
Respiratory function can be compromised by both
obesity & severe malnourishment
BMI should be calculated

25. CARDIORESPIRATORY ASSESSMENT 25
Weakness & wasting of small muscles in hand –
early sign of upper lobe tumour involving brachial
plexus (pancoast’s tumour)
Fingers may show nicotine staining from smoking
Clubbing:
Loss of angle between nail bed & nail itself
Sign of chronic hypoxia
Exact cause is unknown

26. CARDIORESPIRATORY ASSESSMENT 26
Causes of clubbing:
Lung dzs: Infective (bronchiectasis, lung abscess,
empyema)
Fibrotic
Malignant (bronchogenic ca,
mesothelioma)
Cardiac dzs: Congenital cyanotic ht dzs
Bacterial endocarditis
Others: familial, cirrhosis, GI dzs

27. Grades of Clubbing
1. Fluctuation and softening of the nail bed (increased ballotability)
2. obliteration of nail bed angle
3. Overlying skin becomes shiny , Parrot beak/Drumstick appearance
4. Swelling of fingers & pulmonary osteoarthropathy
CARDIORESPIRATORY ASSESSMENT 27

28. CARDIORESPIRATORY ASSESSMENT 28
Schamroth’s sign:
Normally when 2 fingers are held together with
nails facing each other, a space is seen at the level
of approx. nail fold.
This is lost in case of clubbing

29. CARDIORESPIRATORY ASSESSMENT 29
Observation of eyes:
It should be examined for pallor (anaemia)
jaundice (yellow colour due to liver or blood
disturbances)
Drooping of one eyelid with enlargement of that pupil
suggests – Horner’s syndromes (Disturbance in
sympathetic n supply to that side of head)

30. CARDIORESPIRATORY ASSESSMENT 30
Cyanosis : Bluish discoloration of skin and
mucous membrane. Increased reduced Hb

Central : Inadequate uptake of oxygen. Seen in
mouth and tongue which will be warm.
Peripheral : Stagnation of blood seen in extremity
which will be cold.
Mixed:

31. CARDIORESPIRATORY ASSESSMENT 31
JVP :
On the side of neck it is seen as flickering impulse in
jugular vein
Normally seen at base of neck when lying back at
45 degree
It is measured in relation to sternal angle
Normal JVP at the base of neck corresponds to a
vertical height approx 3 to 4 cm above sternal angle
It provides quick assessment of volume of blood in
great vessel entering the heart

32. CARDIORESPIRATORY ASSESSMENT 32
It is elevated in :
Right heart failure
Constrictive pericarditis
SVC obstruction
Ch lung dzs, complicated by cor pulmonale

33. CARDIORESPIRATORY ASSESSMENT 33
Peripheral Edema :
Imp sign of cardiac failure
Also found in : low albumin level
impaired venous or lymphatic
function
high dose steroids

34. CARDIORESPIRATORY ASSESSMENT 34
Observation of chest :
Presence of ICD :
Placed between 2 ribs into pleural space to remove
air, fluid or pus
Used routinely after CT Surgery
Observation must be made of fluid level within the
tube which should oscillate or swing with every
breath
If it doesn’t swing – tube is not patent
Continuous suction – dampens fluid swing

35. CARDIORESPIRATORY ASSESSMENT 35
Chest shape :
It should be symmetrical with the ribs, in adults,
descending at approx 45 degree from spine
Trans dia > AP dia ( 7 : 5 )
Thoracic spine should have slight kyphosis

36. CARDIORESPIRATORY ASSESSMENT 36
Common abnormalities :
Barrel chest : increased AP dia,
ribs less oblique
prominent sternal angle,
arched sternum
Seen in kyphosis of aging or hyper inflation of pul
emphysema

37. CARDIORESPIRATORY ASSESSMENT 37
Funnel chest (Cobbler’s chest, Pectus excavatum) :
Depression in lower part of sternum
May be congenital, following rickets in childhood or
occupational deformity in cobblers

38. CARDIORESPIRATORY ASSESSMENT 38
Pigeon chest ( Pectus carinatum, Keeled chest ) :
Sternum displaced ant

39. CARDIORESPIRATORY ASSESSMENT 39
Breathing pattern :
Normal breathing should be regular with 12 to 16
breaths / min
I : E ratio 1 : 1.5
Types :
Rapid shallow breathing ( Tachypnoea )
Causes : Restrictive lung dzs, pleuritic chest pain,
elevated diaph

40. CARDIORESPIRATORY ASSESSMENT 40
Kussmaul breathing ( air hunger ) :
Ataxic breathing
Cheyne stokes breathing

41. CARDIORESPIRATORY ASSESSMENT 41
Obstructive breathing :
I : E = 1 : 3 or 1: 4
Prolonged expiration due to increased airway resi
If RR increases, pt lacks sufficient time for full
expiration
Air trapping occurs

42. CARDIORESPIRATORY ASSESSMENT 42
Types of breathing :
Males : abdominothoracic
Females : thoracoabdominal
Thoracic : diaph paralysis, peritonitis, ascites
Abdominal : pleurisy, collapse of lung

43. CARDIORESPIRATORY ASSESSMENT 43
Chest movement :
Normally both sides move uniformly & there is no
bulging or indrawing
Accessary muscles not required
Unilateral diminished movement :
obstruction of main bronchus
consolidation
fibrosis of lung, pl adhesions
massive collapse
hydropneumothorax, pl effusion