Info from medical chart
- History of presenting condition
- Previous medical history & drug history
- Family history
- Social history
- Functional history (mobility aids)
- Operation notes
- Special orders (PT, O2, fluid, pain relief)
- Medical diagnosis
- Medical plan
Info from bed chart
- Vital signs
- Medications
- Fluid balance
- blood glucose
- haemoglobin
- neurological status
Patient interview
-Patients main concerns
Respiration
- Breathlessness
- Cough
- Sputum
- Wheeze
- Chest pain
- Specific questions
- Social history
- functional history
- goals
Specific questions
- Asthma (previous admission, icu admission, action plan/management)
- COPD (last exacerbation, change in symptoms, cough, management)
- Diabetes (type, management, sensation in feet)
- Ischaemic heart disease (angina: history, pain area, precipitating factors, exercise tolerance, management)
- Peripheral vascular disease (claudication, sensation in feet, management, skin care)
- Recent URTI
- Smoking history
- Alcohol consumption
- incontinence
Physical examination
- Observations
- Respiratory observations
- Palpations
- Auscultations
- Cough
- Sputum
- LL
- Mobility
- Specific assessment
Observations
- Oxygen
- Nasogastric tube
- IV lines
- Analgesia
- Monitoring
- intercostal catheter
- wound drains
- indwelling catheter
Palpation
Hands- ribs 7-10
- Movement & symmetry (bibasal, apical)
- temp
- fremitus
- subcultaneous emphysema
Respiratory observations
- RR
- chest shape (pectus carinatum, pectus excavatum, barrel chest)
- Breathing pattern (movement & symmetry, upper elevatory, mid-flaring, lower-expansion, abdominal)
- Accessory muscle use
- Paradoxical movement (intercostal drawing, jugular notch, hoover’s sign, respiratory alterations)
Auscultations
Breathing sounds
- localised decrease BS–local airway obstruction
- generalised decrease– large air spaces
Bronchial breath sounds
–> consolidation (solid lungs)–> decreased no of interfaces–> decreased attenuation–> increased BS
Added/adventitious sounds
- Wheeze
- Stridor
- Crackes
Wheeze
Intrathoracic vibrations or flutters of almost touching sides of the airways
- expiration= airways narrower, wheeze more likely/more tense
- Synchronous= when airways obstruct at the same time (late in normal forced expiration
- Asynchronous and multiple= arise from different airways obstructing at different phases of the respiratory cycle
Stridor
Extrathoracic heard at mouth and over the trachea rather than over the chest
-inspiration= diameter of airways is decreased on inspiration
Crackles
Coarse crackles: retained secretions, or diffuse small airway disease
Fine-end inspiratory: atelectasis= sudden opening of distal airways
Fine crackles: diffuse interstitial pulmonary fibrosis, left heart failure
Cough
- Strength (weak, fair, strong)
- Dry/moist
- effective/ineffective
- productive/non-productive
- sputum (quality/quantity)
Sputum
Mucoid
-opalescent or white= chronic bronchitis without infection
Mucopurulent
-Slightly discoloured, not frank pus= bronchiectasis, cystic fibrosis, pneumonia
Purulent thick viscous -yellow= haemophilus -dark green= pseudomonas -Rusty= Pneumonoccus -redcurrent jelly= klebsiella
Frothy
-Pink or white= pulmonary oedema
Haemoptosis
-Ranging from blood spec to frank blood, old blood (dark brown)= Infection, infarction
Black
Lower limbs
- Oedema
- deep vein thrombosis (colour, temp, pal, homan’s sign)
- circulation (dorsalis pedis, posterior tibial)
- peripheral perfusion
- Musculoskeletal (ROm, strength)
- Neurological (sensation, tone)
Mobility
Bed mobility
Gait
Balance
Specific Assessment
Pulse oximetry Epidural Exercise capacity Quality of life questionaire -dyspnoea scalesn
