Patient Assessment Study Notes

Patient Assessment

Part 1: Life Functions, Patient History and Physical Exam, Inspection

Life Functions

  • Four Critical Life Functions: These critical life functions are essential to assess the overall health and viability of the patient:

    • Ventilation: Movement of air in and out of the lungs.

    • Oxygenation: Process of getting oxygen into the blood.

    • Circulation: Movement of blood throughout the body.

    • Perfusion: Delivery of blood into the capillary beds of the tissues.

Ventilation

Definition: The process of moving air in and out of the lungs.

Measuring Ventilation Includes:

  • Respiratory Rate (RR): Number of breaths per minute.

  • Tidal Volume (Vt): Amount of air inhaled or exhaled per breath.

  • Chest Movement: Observing the expansion and contraction of the chest.

  • Breath Sounds: Auscultation of lung sounds to assess airflow.

  • PaCO2: Partial pressure of carbon dioxide in arterial blood, indicating ventilation effectiveness.

  • EtCO2: End-tidal carbon dioxide, the measurement of carbon dioxide at the end of an exhaled breath, reflecting ventilation.

Oxygenation

Definition: The process of getting oxygen into the blood.

Measuring Oxygenation Includes:

  • Heart Rate (HR): Beats per minute, indicating cardiac performance.

  • Color: Assessing skin color for signs of cyanosis or hypoxia.

  • Sensorium: Patient's mental status, alertness, and cognitive function.

  • SpO2/PaO2: Arterial oxygen saturation (% of hemoglobin saturated with oxygen) and partial pressure of oxygen in arterial blood.

Circulation

Definition: The movement of blood throughout the body to deliver oxygen and nutrients.

Measuring Circulation Includes:

  • Heart Rate (HR): The speed of the heartbeat.

  • Pulse Strength: The quality and strength of the pulse.

  • Cardiac Output: The volume of blood the heart pumps per minute.

Perfusion: The process by which blood is delivered to the tissues.

Measures for Perfusion Includes:

  • Blood Pressure (BP): The pressure of circulating blood on the walls of blood vessels.

  • Sensorium: Assessment of mental status which can indicate perfusion adequacy.

  • Temperature: Body temperature measurements can indicate blood flow and functionality.

  • Urine Output: Volume of urine produced; vital for assessing kidney perfusion and overall volume status.

  • Hemodynamics: The dynamics of blood flow, important for evaluating perfusion status.

Assessment of Life Functions

**Critical situations: **

  • If any life functions are absent (e.g. no breathing, no pulse, no BP), you face a Code Blue patient, requiring immediate actions for resuscitation.

    Emergency Priorities:

    1. Ventilation: Establish open airway and ensure breathing.

    2. Oxygenation: Increase the fraction of inspired oxygen (FiO2).

    3. Circulation: Administer chest compressions, utilize defibrillation, and administer heart drugs as necessary.

    4. Perfusion: Focus on increasing blood pressure.

  • The most common issue encountered is oxygenation, which must be prioritized in assessments and interventions.

Reviewing Patient Records

Important components in reviewing patient records include:

  • Patient history and physical exam results.

  • Respiratory care orders detailing the treatment plan.

  • Patient progress notes documenting ongoing condition and treatment response.

  • Intake and output data tracking fluid balance.

  • Current vital signs of the patient.

  • Laboratory values relevant to respiratory care and function.

  • Pulmonary Function Test (PFT) results.

  • Chest X-ray (CXR) findings to assess lung health.

Patient History and Physical Exam

Vital Components:

  1. Admitting Diagnosis and Major Complaint: Clear identification of the primary reason for the patient's visit/admission.

  1. Signs and Symptoms:

  • Signs: Objective data that can be seen or measured (e.g., color, pulse, edema, heart rate, respiratory rate, blood pressure).

  • Symptoms: Subjective data reported by the patient (e.g., pain, nausea, dyspnea).

3. Occupation or Employment History: Relevant past work experiences that may correlate with respiratory issues.

  1. Prior Surgery, Illness, or Injury: Essential historical data to consider.

  2. Vital Signs:

  • respiratory rate (RR)

  • pulse

  • blood pressure (BP)

  • temperature

  • SpO2

  1. Smoking History: Documented in pack years for assessment of respiratory risks.

Respiratory Care Orders

Essential Information to Note:

  • Type, frequency, dosages, dilutions of treatments, and signature of the physician.

  • Oxygen delivery device specifics, percentage or liter flow of oxygen required.

  • Type of ventilator used and prescribed settings.

  • Frequency and duration of each prescribed treatment.

  • Medications ordered that accompany the treatment regimen.

Patient Progress Notes

  • Documentation Required:

    • Respiratory Notes: Documenting the date, time, and any reactions to treatments.

Intake and Output

Normal Urine Output:

  • Approximately 40-50 ml per hour (about 1 liter per day).

Types of Water Loss:

Sensible Water Loss: Observed through urine and vomiting.

Insensible Water Loss: Occurs via lungs and skin.

Definitions of Urine Output:

Polyuria: Urine output exceeding 3L/day.

Oliguria: Urine output less than 0.4L/day.

  • The #1 cause of decreased urine output is heart failure/disease.

  • Consequences of Intake > Output:

    • Weight gain, electrolyte imbalance, increased hemodynamic pressures, and decreased lung compliance.

Current Vital Signs/Normal Values

Vital Sign Ranges (NBRC standards):

Heart Rate (HR): 60 – 100 bpm

Respiration Rate (RR): 12-20 bpm

Blood Pressure (BP): 120/80 mmHg

Temperature (Temp): 37C or 98.6 F (oral)

SpO2: 93-97%

  • Important to memorize these values for clinical evaluation!

Lab Values

Normal Laboratory Findings:

RBC Count: 4 – 6 million/mm3

indicating oxygen-carrying capacity of the blood.

WBC Count: 5,000 – 10,000/mm3

  • elevated = infection

  • may require further testing like a CXR or sputum culture.

ABG’s (Arterial Blood Gases):

  • assess acid-base disturbances (e.g., ( ext{pH/PaCO2/HCO}_3)

  • check arterial oxygenation (PaO2)

PFT Results

Purpose of Pulmonary Function Tests (PFT):

  • Evaluates pulmonary causes of dyspnea.

  • Differentiates between obstructive and restrictive disorders.

  • Assesses severity of any pathophysiologic impairment.

  • Follows the disease course over time.

  • Evaluates therapy effectiveness (e.g. pre- and post-bronchodilator studies).

  • Determines patient's preoperative status.

Chest Radiography (CXR)

Purpose of CXR:

  • Diagnosing lung disorders and identifying issues that may affect respiratory function.

  • Assessing the extent and location of lung disease.

  • Evaluating subsequent progress of the disease post-treatment.

Patient Interview/History

  • Interview Strategies:

    • Develop a plan during the patient interview and examination.

    • Ask a combination of open-ended and closed questions to gather comprehensive information.

    • Aim to identify the patient's major health concerns.

    • Utilize simple language to communicate effectively with patients.

    • For non-native speakers or illiterate patients, employ visual aids like pictures and diagrams.

Evaluating Sensorium

Assessing Orientation:

  • Current date

  • Location

  • Name

  • Situation

Important Questions to Ask:

  • Ensure to ask questions to evaluate consciousness and cognitive state.

Determine Level of Consciousness

Consciousness Levels:

  1. Normal: Alert, oriented, cooperative.

  2. Confused: Slightly decreased consciousness and slow mental responses.

  3. Delirious: Easily agitated, irritable, possible hallucinations.

  4. Lethargic: Sleepy but can be aroused and responds appropriately.

  5. Obtunded: Awakens with difficulty, but responds when aroused.

  6. Stuporous: Does not fully awaken, exhibits decreased mental and physical activity, and responds only to pain.

  7. Comatose: Unconscious, unresponsive to stimuli, and devoid of voluntary movement.

Questions to Ask

Key Questions for Patient Interaction:

  • Current chief complaint.

  • Duration of the current chief complaint.

  • Difficulty breathing?

  • Cough? (Productive or Non-productive?)

  • Medical history regarding any cardiac or pulmonary diseases.

Additional Questions to Ask

  1. Inquire on Self-Care Behaviors:

Current vaccinations, TB skin tests, most recent CXR, etc.

  1. Ask about Family History:

Allergies, asthma, smoking or significant exposure to second-hand smoke, cardiac issues, pneumonia, tuberculosis (TB), and familial respiratory conditions such as emphysema not linked to smoking (e.g., alpha-1 antitrypsin deficiency).

  1. Assess frequency of colds in children

  • with normal expectations being 4 – 6 upper respiratory infections per year.

  1. Relevance of Employment History:

  • Document if the patient has worked in occupations that may impact respiratory health (e.g., mining).

Physical Examination

Importance: Critical for evaluating the patient’s respiratory issue and determining treatment effects.

Physical Examination Sequence (IPPA):

  1. Inspection: Visual examination of the patient.

  2. Palpation: Physical touching and examination for abnormalities.

  3. Percussion: Tapping the body to assess the underlying structures.

  4. Auscultation: Listening with a stethoscope to hear internal sounds such as lung breath sounds.