Cardio Pulmonary Assessment [PDF]

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Cardiopulmonary Assessment General Information: Name: Age: Sex: Presenting Complaints:



Subjective Assessment: History: History of Present illness: Onset, Duration, Severity Past Medical History/Drug History/Surgical History: illness/surgeries/injuries/immunizations/allergies/hospitalizations/drugs presently being taken Personal History: Drug abuse/ smoking/alcohol (Pack years) Family & Social History: Family type/Physical, Emotional and Economic support in the family Family health/ hereditary disorders Occupational History: Particles/dusts/fumes/gases pertaining to various occupations.



Respiratory Symptoms Dyspnea: Grade/ Type Cough: Type/Characteristics/Productivity/24 Hr Pattern Sputum: Quantity/Color/Consistency/Odor Chest Pain: Location, Radiation, Character, Frequency, Intensity, Aggravating, Relieving factors. Vital Signs: Temperature, Heart Rate, Respiratory Rate, Blood Pressure.



Observation/Inspection: Built of the patient: Ectomorphic/ Mesomorphic /Endomorphic Integumentary system: Incision/Scar, Ulcers/ Wounds, Skin color/IV sites/ Catheters/ IC drainage/Any other equipments or tubes connected to the patient. Facial Features: Dilation of pupil/Nasal Flaring/Sweating/Pallor Neck: Jugular venous Pulse/ Accessory muscle usage. Cyanosis: Central – Mouth, Tongue, Lips /Peripheral- fingers, Ear lobes, toes



Hand: Clubbing – Absent/Present (Grade) Tremor, Wasting of muscles, Nicotine Stain Edema: Pitting/Non Pitting, Bilateral/ Unilateral, Facial edema Chest appearance and movements: Respiratory Rate: Type of breathing: Thoracic/Abdominal Abnormal breathing pattern: Thoracic index: Deformities: Spinal/ Chest



Objective Assessment: Examination: Chest expansion/ Thoracic mobility: Normal/ Increased/Diminished Trunk Mobility (ROM of the Spine) – Normal /Diminished Shoulder Mobility (ROM of the shoulder Joint) – Normal /Diminished



Auscultation: Breath sounds: Bronchial, Broncho-vesicular and vesicular- Normal/Abnormal Adventitious Lung sounds: Wheezes and Crackles - Present/Absent Vocal resonance: Bronchophony/Egophony/Whispered Pectoriloquy- Normal/Abnormal Heart sounds: S1, S2, and S3 & S4 Murmur (Systolic/Diastolic): Present/Absent Friction Rub: Pleural/Pericardial



Percussion: Right Lung: Upper Lobe/Middle Lobe/Lower Lobe Left Lung: Upper Lobe/Lower Lobe



Palpation: Tracheal/Mediastinal Shift: Present (Right/Left)/ Absent Chest Wall Excursion/Thoracic Expansion: Normal/Diminished Diaphragmatic Excursion: Inches of Thumb separation: > 5 Cm / < 5 Cm



Vocal fremitus/Tactile fremitus: Normal/Increased/Decreased Accessory Muscle Usage: Present (Muscles Used)/ Absent Tenderness: Present (Grade)/Absent Local Skin Temperature: Normal/Cold/Increased Warmth Edema: Pitting/Non Pitting. U/L, B/L, Feet, Hand, Facial Pulse Examination: Radial, Brachial, Carotid, Femoral and Dorsal Pedis artery. Point of Maximal Impulse (PMI): Normal/Shifted (right/left) Capillary Refill Time: > 2 seconds/< 2 Seconds



Investigations: Blood Study: RBC, WBC, Platelets, ESR, Lipid Profile, Electrolytes study. Histological, Cytological, Microbiological Analysis: Carcinoma, infections etc X-Ray: To assess Lung and Heart conditions ECG: To analyze the electrical activity of Heart Spirometry/PFT: To find Obstructive and Restrictive lung diseases Pulse Oxymetry: For oxygen saturation. ABG: To find the pH, assess acidosis and alkalosis Echocardiography, CT/MRI Scan, Angiogram, Bronchoscopy Exercise Tolerance test: To find cardiopulmonary capacity.



Problem List: Short Term Goals: Long Term Goals: Treatment: Home Program



Grades of Dyspnea



Class I



No symptoms with ordinary activity



Class II



Symptoms with ordinary activity



Class III



Symptoms with mild exertion



Class IV



Symptoms at rest



Characteristics of Cough Type of Presentation



Possible Causes



Dry



Asthma, ILD, Recent viral infections, Pollutants, ACE inhibitors



Productive



COPD, Bronchiectasis, Lung infections



In position change



GOR, asthma, Heart failure



Chronic Persistent



GOR, Post nasal drips



With eating or drinking



Aspiration, Neurological illness, elderly people



With exertion



Asthma, COPD, ILD



Weak/Inadequate



Muscle weakness, Pain, After surgery, Elderly, Poor understanding



Paroxysmal



Asthma, aspiration, Upper airway obstruction.



Characteristics of Sputum Appearance



Possible causes



Frothy – Mixed with air



Pulmonary edema



Mucoid



COPD without infection



Purulent – Yellow, Dark green, Rusty



Homophiles, Pseudomonas, Pneumococus, Mycoplasma



Black



Smoke inhalation, coal dust



Hemoptysis



TB, Bronchiectasis, infarction, Carcinoma, Vasculitis, Trauma



Grades of Clubbing Grade 1



Description Softening of nail bed



2



Obliteration of angle(Lovibond angle)



3



Parrot beak or drumstick appearance



4



Hypertrophic pulmonary osteoarthropathy



Grades of Edema Grad e



Description



1+



Indentation is barely detectable



2+



Slight indentation visible when skin is depressed, returns to normal in 15 seconds



3+



Deeper indentation occurs when pressed and returns to normal within 30 seconds



4+



Indentation lasts for more than 30 seconds



Breathing Patterns in Respiratory problem. Pattern of Breathing



Description



Apnea



Absence of ventilation



Fish-mouth(gulp)



Apnea with mouth opening & closing; along with neck extension & bradypnea



Eupnea



Normal rate, normal depth, regular rhythm



Bradypnea



Slow rate, shallow or normal depth, regular rhythm; associated with drug overdose. RR less than 10 BPM



Tachypnea



Fast rate, shallow depth, regular rhythm; associated with restricted lung disease



Hyperpnea



Normal rate, increased depth, regular rhythm



CheyneStokes(periodic)



Increasing then decreasing depth, period of apnea interspersed; somewhat regular rhythm; associated with critically ill patients



Biot’s Breathing



Slow rate, shallow depth, apneic periods, irregular rhythm, associated with brain stem disorders



Prolonged Expiration



Fast inspiration, slow and prolonged expiration yet normal rate, depth, and regular rhythm, associated with COPD



Hyperventilation



Fast rate, increased depth, regular rhythm; results in decreased arterial carbon dioxide, tension ; called “Kussmaul breathing” in metabolic acidosis



Door Step Breathing



Normal rate and rhythm; characterized by abrupt cessation of inspiration when restriction is encountered; associated with pleurisy



Grades of Tenderness Grad e



Description



I



Patient complaints of pain



II



Patient complaints of pain and winces



III



Patient winces and withdraws



IV



Patient will not allow palpation



Pulse Grading Grade 0 1+ 2+ 3+ 4+



Description No pulse Weak pulse, difficult to palpate Palpable but not normal, diminished Normal, easy to palpate Bounding, very strong, possibility of an aneurysm



Percussion Tones Tones



Description



Resonant



Loud or high amplitude, longer duration, heard over air filled organs like lungs



Dull



Low amplitude, short duration, heard over solid organs like liver



Flat



High-pitched, short duration, heard over muscle mass such as thigh



Tympanic



High-pitched, medium duration, heard over hollow structures like stomach



Hyper-Resonant



Very low-pitched, prolonged duration, heard over tissue with decreased density (increased air & tissue ratio) Heard in emphysema



Mediastinal Shift Description Condition



Atelectasis Lobectomy Pneumonectomy Pleural Effusion Pneumothorax Herniation of abdominal viscera



Direction of Shift Ipsilateral Contralater al      