Assessment tools

Chapter 3 Assessment tools




3.1 Arterial Blood Gases (ABGs)


3.2 Attachments


3.3 Auscultation


3.4 AVPU


3.5 Blood Pressure (BP)


3.6 Blood Results


3.7 Breathing Pattern (See under 3.54 Respiratory Pattern – Page 148)


3.8 Breathlessness (Dyspnoea) Scales


3.9 Capillary Refill Test


3.10 (Invasive) Cardiac Monitoring


3.11 Central Venous Pressure (CVP)


3.12 Cerebral Perfusion Pressure (CPP)


3.13 Chest Drains


3.14 Chest Imaging (Including Chest X-rays)


3.15 Chest X-ray (See under 3.14 Chest Imaging – Page 68)


3.16 Chest Wall Shape


3.17 (Digital) Clubbing


3.18 Consent


3.19 Cough Assessment


3.20 Cyanosis


3.21 Dermatomes


3.22 Drugs


3.23 Early Warning Scores (EWS)


3.24 Electrocardiogram (ECG) (See under 3.35 Heart Rhythms – Page 109)


3.25 Electrolytes (See under 3.6 Blood Results – page 49)


3.26 End-Tidal Carbon Dioxide (ETCO2) 92


3.27 Exercise (aerobic fitness) Testing


3.28 Exercise Tolerance


3.29 FEV1/FVC (See under 3.40 Lung Volumes and Lung Function Tests – Page 120)


3.30 Flow Volume Loops (See under 3.40 Lung Volumes and Lung Function Tests – Page 120)


3.31 Fluid Balance (Including Urine Output)


3.32 General Observation (See Chapter 1)


3.33 Glasgow Coma Scale (GCS)


3.34 Heart Rate (HR)


3.35 Heart Rhythms


3.36 Inspiratory Muscle Testing (See under 3.40 Lung Volumes and Lung Function Tests – Page 120)


3.37 Intracranial Pressure (ICP)


3.38 ITU (critical care) Charts


3.39 Level of Consciousness


3.40 Lung Volumes and Lung Function Tests (Pulmonary Function Tests)


3.41 Muscle Charting (Oxford Grading)


3.42 Myotomes


3.43 Oxygen Delivery


3.44 Pain Score


3.45 Palpation


3.46 Peak Flow (See under 3.40 Lung Volumes and Lung Function Tests – Page 120)


3.47 Percussion Note


3.48 Pulse Oximetry


3.49 Pupils


3.50 Quality of Life Questionnaires


3.51 Rating of Perceived Exertion (RPE)


3.52 Reflexes


3.53 Renal Function (See under 3.6 Blood Results and 3.31 Fluid Balance – Pages 49 and 102)


3.54 Respiratory Pattern


3.55 Respiratory Rate (RR)


3.56 Resuscitation Status


3.57 Sedation/Agitation Score


3.58 Sputum Assessment


3.59 Surgical Incisions


3.60 Swallow Assessment


3.61 TPR (Temperature, Pulse and Respiration) Chart


3.62 Ventilation–Perfusion (V/Q) Matching


3.63 Ventilator Observations


3.64 Work of Breathing


This chapter contains assessment procedures that may be used with respiratory patients. For each assessment performed, you need to select those that are most appropriate for each patient. If you are unsure which are appropriate, refer back to the assessment checklists in Chapter 2, which relate the tools to the assessment process.


There are many texts available that briefly discuss assessment tools. This book aims to cover these techniques in a standardized format. It gives a simple, step-by-step explanation of exactly how they are performed and how to interpret the findings.


Each technique has distinct sections:



Literature and clinical practice vary widely; therefore, each assessment tool is based on a consensus of identified articles, key texts and clinical experience. In line with other titles in this series, an amalgamation of evidence style has been taken to allow for a standardization of the text. Specific texts and examples of further reading are at the end of each assessment tool as appropriate. For ease of use, this chapter is in alphabetical order. Please note that many of these procedures are referred to using different terminology depending on your work setting and location.



3.1 Arterial blood gases (ABGs)





Procedure


Physiotherapists need to be able to analyse the results (Fig. 3.1.1). The procedure itself involves taking an arterial blood sample and is normally carried out only by medical or nursing staff and some extended scope physiotherapists with specialized training.




Findings (Fig. 3.1.2, Table 3.1.1)


You should also consider haemoglobin (Hb) levels when interpreting ABG results (see 3.48 Pulse oximetry). Fig 3.1.2 summarizes the process of interpreting ABG’s in flowchart format.



Table 3.1.1 Blood gas measurements





















pH
PaCO2
PaO2
SaO2
image
BE (base excess)

NB. Partial pressure refers to the pressure exerted by one specific gas (e.g. oxygen), which forms part of the total pressure exerted by the mixture of gases (e.g. oxygen, carbon dioxide and nitrogen) in the blood.


Process of Interpreting ABGs.



1. Check pH




2. Check PaCO2







3. Check image (or BE)






4. Check for compensation







The chart in Table 3.1.2 assumes that any compensation is complete not partial.

5. Check oxygenation





6. Check for respiratory failure


















3.3 Auscultation





Procedure




Equipment




Method















Table 3.3.1 Auscultation zones















Anterior

Mid-axillary   Left and right
Posterior



Findings


For each zone, record whether breath sounds are normal or bronchial, loud or quiet, and then identify any added sounds.


Breath sounds (Table 3.3.2) arise in the trachea and bronchi and are caused by the turbulence of the air as it flows in and out of these large airways. If you listen over the trachea (just below the cricoid cartilage or Adam’s apple) you will hear what they sound like at the source.You will notice that they are very loud here and also quite harsh sounding. Inspiration and expiration are heard clearly (both are loud) and there is a very slight pause between them. These sounds are known as bronchial breath sounds because they are generated in the bronchi (and trachea).



Normal breath sounds. If you listen anywhere over the lung fields (including all of the zones shown in Fig. 3.3.2) the sounds are much quieter because you are over lung parenchyma and the air in the lungs has absorbed a lot of the sound. This attenuates the sound, making it smoother, gentler and more continuous, so it is harder to tell when inspiration changes to expiration. Since we expect to hear these sounds when auscultating over the lungs we call them ‘normal breath sounds’.


Bronchial breathing (bronchial breath sounds heard over lung fields). If you are listening over the lungs and what you hear sounds loud, harsh and discontinuous (i.e. like bronchial breath sounds), it is not ‘normal’ and suggests that these sounds have not been dampened down by the air in the lungs – usually because in that area of lung the air has been replaced by something solid (consolidated). A solid area transmits sound very well because it vibrates more than air (ask the patient to say ‘99’ while auscultating and the sound will be very clear over consolidated lung tissue). These sounds may occur over an area of lobar pneumonia where the alveoli fill with clotted inflammatory exudate, or over collapsed lung tissue (occurring without a sputum plug), or at the lip of a pleural effusion.


Breath sounds quieter than normal. If the breath sounds are very quiet it might be because the patient is very large and therefore the sounds have been dampened down by excess soft tissue. Make sure you press the stethoscope firmly to the chest wall and press through the adipose tissue to get the best sound transmission. It might, however, be because the breaths were quite small and not generating much turbulence. Perhaps the patient is not breathing very deeply? Does this fit with your observation and palpation? Is one side of the chest moving more than the other side?


Table 3.3.2 Breath sounds














Turbulence in the large airways



If heard over lung fields, suggests:






May be due to:








Absent breath sounds. A pleural effusion, sputum plugging or pneumothorax could prevent sounds from being heard by absorbing the sound completely before it can be transmitted to the chest wall.




Breath sounds louder than normal. Loud breath sounds suggest more turbulence in the large airways. This is usually due to obstruction or narrowing of these airways, e.g. due to COPD. Narrower airways are harder to breathe through, so the patient may be working harder in order to breathe.


Other added sounds.





Table 3.3.3 Added sounds: crackles




















Crackles Short, non-musical, popping sounds, fine or coarse
Fine crackles
Atelectasis


Intra-alveolar oedema


Secretions small airways


Coarse crackles
Obstruction more proximal and larger airways with sputum. May be inspiratory as well as expiratory





Wheezes (Table 3.3.4). Whistling sounds due to narrowed airway walls vibrating against each other, indicating airway obstruction. High-pitched wheeze indicates bronchospasm or oedema in the walls of conducting airways. Low-pitched wheeze indicates sputum.


Pleural rub (Table 3.3.5). A sound like boots crunching on snow suggests that the pleura are inflamed.

Stridor (Table 3.3.5). This is a sound like a loud ‘barking’ noise. Occurs during both inspiration and expiration and is usually caused by significant upper airway obstruction, which could be a foreign body or tumour. If stridor is heard as a new/recent symptom, alert the medical staff immediately as the patient’s airway could be compromised.

Table 3.3.4 Added sounds: wheezes


















Wheezes Musical sounds due to vibration of wall of narrowed airway
High pitched Bronchospasm
Low pitched Sputum

Localized TumourForeign body

Table 3.3.5 Other sounds















  Sounds like Cause
Pleural rub






Stridor




! Alert medical staff as the patient’s airway is at great risk of compromise

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Jun 11, 2016 | Posted by in RESPIRATORY | Comments Off on Assessment tools

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