Scribd Logo
Upload

Welcome to Scribd!

  • Essentials of CP PT Chapter 16

    Uploaded by

    Carolina Bejarano Gonzalez
    11 views36 pages

    Original Title

    Essentials of CP Pt Chapter 16

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    11 views36 pages

    Essentials of CP PT Chapter 16

    Uploaded by

    Carolina Bejarano Gonzalez

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 36
    cHapter 16 Chapter Outline Elements of Patient Management Preferred Physical Therapist Practice Patterns Patient History Medical Chart Review Diagnosis and Date of Event Symptoms Other Medical Problems and Past Medical History Metications Risk Factors for Heart Disease Relevant Social History Clinical Laboratory Data Radiologic Studies Oxygen Therapy and Other Respiratory Treatment Surgical Procedures Other Therapeutic Regimens Electrocardiogram and Serial Monitoring Pulmonary Function Tests Arterial Blood Gases Cardiac Catheterization Data Optimal rehabilitation depends on a thorough examination fof the entire patient to evaluate the extent of dysfunction tha may affect future performance. In this chapter, the exam ination procedures, used to provide information regarding specific cardiopulmonary-system diseases are described. The ‘examination includes a systems review prior £0 an entire examination as well 35a battery of tests and measures. While performing the initial examination, objective information fan be obrained from a thorough review of the medical record, an interview with the patient, and an assessment of the patienc at rest (including observation and inspection, palpation, auscultation, mediate percussion, general muscle strength, and joint range of motion) and during activity. In sxidition, the physical therapist must also have a good undet- standing of other therapeutic regimens and concomitant problems and be able to recognize them. On conclusion of the examination, the therapist should be able to interpret the evaluative findings appropriately to make a decision regard- ing therapeutic interventions. Hlements of Patient Management The process involved in determining the most appropri ate interventions to address and ultimately achieve the 534 Examination and Assessment Procedures Ellen Hillegass Exsertals o Cardiopelranary, mals of oaipheoror Vital Signs Hospital Course Nutitional Intake Occupational History Home Environment and Family Situation Interview with the Patient and the Family systems Review Physical Examination Inspection ‘Auscultation ofthe Lungs ‘Auscultation of the Heart Palpation Mediate Percussion Activity Evaluation Evaluation Case Study Summary References desived outcomes for the patient involves six elements ig. 16-1) 9 Examination: A comprehensive patient screening of history and a systems review as wel as specific tests and measures to collect data on the patient. Evaluation: Evaluation of the data from the examination to make a clinical judgment > Diagnosis: Deteriining the impact of a condition on function at the level ofthe system and the level of the individual. This diagnosis classifies a patient within @ specific practice pattern and indicates the primary dysfunctions to guide the therapist toward interventions that should be addressed initially. These are not ro be confused with medical diagnoses. Prognosis: Determining the patient's predicted level of ‘optimal function as well asthe estimated lenge of time to achieve expected improvement. A plan of care is developed based on the prognosis, which includes anticipated goals and expected outcomes, 2 Intervention » Outcomes Once. the elements have been performed, a plan A care is established. Re-examination begins, implementing the process of performing rests andl measures co eval the patients progress with subsequent modifications © CHAPTER 16 Examination and Assessment Procedures 535 DIAGNOSIS. Both he process and ta er est of eval EVALUATION dynamic process in wc he ‘physical tharapist malas nes Judgments bases onda gat ‘ted curing th exarination Ts ress also may ony posbie problems mat requre consuaion ttn a ttoral to anor prose. EXAMINATION ‘he proces of eaing shen, pafoming a systems revi, ard Sokctng and aanestonng os land mageures io gather data about the panto Tho ital ‘raminaten i aconprcherao Screening and spect testing process ha eas oa diagno ‘Sossieaon. The exsnunaton ‘ress a0 may ently posse ‘roblems that requreconsulaion ‘ith or rater to anther pro ‘outcomes atone Results of patencfent management which | henaod os conan wh or fi Ineude ha mpact of yal horny ino ofa a anoher power Gomes. orexogerio to help determina the progrss cling th plan cra) and ess spmemevtrmsacs Seer |S entens nts flowing domains pathology! Bahoonysology (Beato, arto cond {ha most apport ntawenton salen = = PROGNOSIS (Including Plan of Care) Datenaton ofthe vel ot ‘optimal mgcoveren at ay Beatanod tug are Non ante aount ne INTERVENTION. Purpocetul ard sad ration of the ysl harpist with he Patoneion an appropiate, ‘ith other nels maha q {are of he patente, using va- ‘us pyc therapy rocodures ara Techniques to produce changes in ‘ns conditon that ate coon | hb agnosis and prognoss. Ta | physical therapist conducts areexam- fraonta detemine enanges in | patenlon satus snd tomodly or Fodrectintewenton Tne 00 {Beaxamine maybe based on ne) inal incisor on ack of pation: progiacs. The process oh {ton} inparmerts once! nations, Diagnosis and date of event © Syinpeoms on admission and after the patients admission © Other significant medical problems in the past medical history © Current medications 2 Risk factors for cardiovascular and pulmonary disease 9 Relevant social history, including smoking, aleoho! and dleugwse, lifestyle, support mechanisms © Clinical laboratory data © Radiologic studies © Oxygen therapy and other respiratory treatment © Surgical procedures © Other therapeutic regimens © Electrocardiogeans and telemetry monitoring © Pulmonary function tests © Arterial blood gases 9 Cardiac catheterization data 2 Other diagnostic tests © Vital signs 2 Hospital course since admission, particularly in the patient with cardiac injury to determine whether it has been. a complicated or an uncomplicated course © Nutritional intake 2 Occupational history © Home environment assessment Diagnosis and Date of Event ‘The physical therapist needs to know and understand the primary diagnosis as well as any additional diagnoses made since the hospital admission oF referral to rehabilitation to decermine the appropriateness of treatment and the need for monitoring of the patient's responses. Often a patients primary diagnosis may have been the reason for admission (cag. a fractured hip), yet a secondary diagnosis may be the reason for referal for physical therapy (e.., pneumonia pore ‘operatively). Any diagnosis that begins "Rule out—" equi 1 thorough review of the chart to see if the diagnosis was confirmed or rejected. “The date of the event is significant, because it determi the acuteness of the situation. The date of the primary event ot diagnosis is often documented in the physician’s histor! and physical examination report; however, reviewing the physician's progeess notes or onders may discover the date the secondary diagnosis or subsequent events. Symptons Both cardiovascular and pulmonary symptoms need t0 PE evaluated, Cardiac ischemic symptoms are those that 0€U anywhere above the waist; they are typically expressed oF" * CHAPTER *Carsiovasoular * Racefethniciy * Gastrointestinal + Pemary language E Education eee Integumentary fi Social History * Museuloskoetal bs + Cutural batts and behaviors Nouromuscular «Family and caregiver resources bsetica + Social interactions, social ‘activites, and suppor ystems “EmploymentWork (WobrSchoovPiay) z * Current and prior work i (job/schootpay), community, b and leisure actons, tasks, aclivties Grovith and Development + Developmental nistory Hand dominance « Psychological *Puimonary Living Environment ‘Devices and equipment og, assistive, adaptive, ott, pro tectve, supporive, prosthetic) “Living environment and ‘community characterises + Projected discharge destinations General Health Status (Gell-Report, Family Report, ————/ Caregiver Report) * General health perception + Physical function (og. mobility, ‘sleep pattems, resticied bed ays) + Peychological function (69, memory, reasoning ability, dopression, anxily) ‘Fle function (eg, community leisure, socal, work) + Socal function (e, social activity, soca intoraction, social support) SocialHealth Habits (Past and Current) *Bahavoral heath risks (eg. smoking, drug abuse) ‘Level of physica! ness Family History ‘Fail haath sks exacerbated by, exertion and are relieved with rest. Bach Fatient may describe these symptoms differently. Classically, any discomfort, such as chest pain, tightness or pressure, shortness of breath, palpitations, indigestion, and burnin should be considered a cardiac symptom unless cardiac dys- function has been ruled out. Reviewing the patients symp: toms on admission and during hospitalization provides the therapist with an awareness of those symptoms that ate to be MedicalSurgical History + Endocrine/metabotic + Prior hospitalizations, surgeries, ‘and preexisting medical and ‘thor heath elatod conditions 16 Examination and Assessment Procedures 537 ‘Current Consition(sy Chief Complaints) *Canearns that ed tho patient to seek the senvies ‘fa physica! therapist + Conearns or needs of patienVoient who requices the Services of a physical herapist ‘Curent therapeutic Intervent ‘+ Mechanisms of injury or disease, Including date of onset and course of events + Onset an pattem of symptoms + Patientichent, family, significant other, and caregiver expcta- tions and goals forthe therapeu- tie imtorventon + Patientiont, family, sgnicant ‘other, and caregiver perceptions of pationts/ctonts emetional response to the current cinical situation + Previous occurrence of let complains) + Prior therapeutic interventions Functional status and Aativty Level Current and pris functional Staus in sl-care and nome ‘management, including atvtias (of daly living ADL) and instru- ‘montal actives of dally ving (ADL) + Current and prior functional satus in work ob/schootpay). ‘communi, and leisure actions, tasks, or actives editions * Medications for currant ‘conan * Medications previously taken for ‘current condition + Medications for other constions Other Clinical Tests: + Laboratory and ciagnostic ests * Roviow of availablo records (09, maical, education, surgical) + Review of oer cinical ndings (eg, nutlion and hylan) Figure 16-2 Types of data that may be generated from a client history. n this model, data about the visceral systems is reflected in the medicalsurgical history The data collected in this portion of the patient history is not the same as information Gollected during the Review of Systems (ROS). It has been recommended that the ROS component be added to this figure. Grom American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd ed. Baltimore, APTA, 2003.) assessed as cardiac or noncardiac. During activity, che thera- pist may be trying to reproduce those symptoms as well as observe for new ones. Ischemic-related sympcoms may also be present in other vasculature of the body, and they too should be assessed (such as claudication discomfort in lower extremi> ties indicate peripheral arterial disease). Angina is discussed in greater detail later in this chapter under abnormal responses luring activity evaluation 538 SECTION 6 Cardiopulmonary Assessment and Intervention Classic pulmonary symproms are described as shortness of breath, dyspnea on exertion, audible wheezing, cough, increased work of breathing, and sputum production. The symptoms and thei severity as well asthe means of reproduc- ing these symptoms are important to identify. Changes in. these symptoms (eg., worsening of symptoms vs. improve tment) assist the therapist in developing a plan of care that meets the patient's changing needs Other Medical Problems and Past Medical History ‘The patient’s past medical history including other medical problems, may have a beating on the evaluation or the plan of treatment proposed by the therapist. Diagnoses other than cardiovascular and pulmonary may include orthopedic, nev rologic, psychological, or integumentary, and these diagnoses ‘may affect the optimal treatment plan proposed. For example, an attempt to inerease the activity level of a patient with a history of rheumatoid arthritis may be limited by an ortho- pedic (joint) dysfunction rather than by a cardiovascular of pulmonary condition, Medications ‘The medications the patient is currently taking are usually listed in the chart (often in the physician's orders). In the inpatient setting, a comprehensive listing can be found on the nurse's medication chart. Knowledge of the patient's medications can provide information about the patient’ present or recent-past medical history and may include clues regarding treatment for hypertension, heart failure, angina, bronchospasm, infection, and the like. In the outpatient setting, the patients should always be asked to bring either 8 listing oftheir curcent prescribed as well as over-the-counter ‘medications and herbal supplements or the actual medication containers, and these medications should be documented in their outpatient chart. Because certain medications may affect the patient’ responses to exercise, the physical therapist must become familiar with the broad categories of cardiac and pulmonary medications, understand the indications for their use, and know their general side effets: For further discussion of medi- cations and their indications and side effects, see Chapters I4and 15, Risk Factors for Heart Disease From the history and physical examination, one wsually can determine whether the patient has any ofthe following major ris factors for heart disease © Hypertension © Smoking © An elevated serum cholesterol or a diet high in cholesterol 2 A family history of heart disease 9 Stress (anger and hostility: personality factors) 2 A sedentary lifestyle Older age Male gender Obesity Diabeces ‘An awareness of the patient’ risk factors enables the ther. apist to develop realistic goals for the patients long-term treatment, 10 identify other echabilitation team metabers to ‘whom the patient should be refered, discuss a plan for pre. vention, and most important, to decide on precautions to and monitoring of increased activity, depending on the tisk for heart disease. Detailed information on the risk factors can be obtained from Chapter 3 Relevant Social History Self-abusive social habits, such as excessive drinking of alcohol, smoking, and use of illicit drugs, can affect the car diopulmonary system and could affect rehabilitation. There- fore, knowledge of the patient’ habits, including the length ‘of time involved in dhe habit and the degree of intake, is an important component of the evaluation. Some ofthis infor: ration can be obtained from the history and physical exami- nation, but often this information. is obtained from the patient or the fail. Heavy alcohol consumption has been associated with the development of cardiomyopathy, and long-tetm cigarette smoking has been associated with che development of chronic obstructive lung disease and also affects wound healing. Drag use is one habit that may not be readily acknowledged but that may be suspected from the individuals behavior (e extreme nervousness), history of sleeplessness, muscle wwitch- ing, anorexia, and nasal itritation. For example, cocaine bas serious effects on the cardiovascular system, particularly om the coronary arteries. Cocaine is known to cause severe coronary attery spasm and in some cases can precipitate acute myocardial infarction.’ © Cocaine use (especially crack cocaine) has been associated with an increased incidence of severe aithythmias and in some cases sucklen death. ‘The physician or other medical personnel treating the patient may be unaware of the patient's heavy alcobol con sumption or drug addiction. Either of these conditions could prove to be an extreme problem eatly in the patient’ hospi talication because of the symptoms and side effects of sudden withdrawal from these substances, Clinical Laboratory Data Laboratory data provide important objective information regarding the clinical status ofthe patient with cardiopullmo” nary dysfunction. The seriousness of the dysfunction may #49 bee inferred from the magnitude of deviation of the values from nortnal. The laboratory data specific to the patient with cardiopulmonary dysfunction include the values for cardia¢ ‘enzymes (troponin, creatine phosphokinase, lactate deb genase, aspartate aminotransferase), blood lipids (choles tnd triglycerides), complete blood cell coune (specfcalt hemoglobin, hematocrit, white blood cell count), BUN # CHAPTER 16 Examination and Assessment Procedures 539 nine, arterial blood gases, and culture and sensitivity, as tas the results of coagulation suis, electrolyte screening }Fanels, and glicose tolernce tests. These are discussed in seater detail in Chapters 8 and 10. | radiologic Studies Ja most situations the therapist reviews the radiologte report jad noc the actual study fils because of lack of access. The F adiologic reports chat are routinely reviewed for patients sith cardiopulmonary dysfunction include chest radiographs, | computed tomography (CT) scan, magnetic resonance ‘imaging (MRI), and scintigraphy. ‘The chest radiographs provide a general static assessment “cfpathologic conditions ofthe lungs and chest wall, includ- | ing changes in functional lung space, pleural space, chest wall, configuration, presence of fluid, heat size, and vascularization ofthe lungs. Information about the extent of hear failure or cardiomyopathy as well as pneumonia, restrictive lung disease, pleural effusion, and the like can be obtained from the chest | radiograph, In addition to baseline chest radiographs, patients with heat failure and acute pulmonary dysfunction ean, be fol lowed with serial radiographs to monitor disease progression, effectiveness of treatment, or both. Therefore, iis important ronote the date ofthe radiograph (particularly ifthe patient's stats fluctuating). Also the orientation of the chest radiograph is important to identify, The ideal chest radio- raph is a posterior-anterior (PA) film taken at a distance of approximately 6 fect with the patient in an upright posi- tion and performing a maximal inspiration. Portable equip- ment utilizing the anteroposterior (AP) orientation is used to take chest films of patients who are too sick or unstable tobe transported to the radiology department fora standard PA film. The quality of the film taken with portable equip- ment and using the AP orientation is generally poorer than a PA film owing to the position of the patient and the patient's inability to cooperate or 10 perform a maximal insptation, The therapist should keep these limitations in tind when evaluating the findings of a portable AP chest radiograph, Oxygen Therapy and Other Respiratory Treatment The use of supplemental oxygen should be noted along with its method of delivery (eg, nasal cannula, face mask, trache ‘oxtomy collar, blow-by ventilator, or mechanical ventilator), swell as the actual breathing performed by the patient with the oxygen in use. Ifa patient is a mouth breather and is ven supplemental oxygen via nasal cannula, he patient will not obiain the maximal benefit from the supplemental oxygen. The physical therapist must also know the amount of oxygen being delivered (eg, 60% via mask or 2 L via ‘annula). This information should be correlated with areerial blood gas analysis or hemoglobin saturation data to deter- nine ifthe patiene is adequately oxygenated before beginning any therapy. Depending on the arterial blood gas or oxygen saturation information, the therapist may need to use oxygen ‘or @ increase the amount of oxygen while exercising the patient (eg, during formal exercise, activities of daily living, ait). Any patient with a resting PO of less chan 60 mm He ‘on room air or an oxygen percentage saturation of less than, 90% should be considered for supplemental oxygen. If a patient has a low PO: bat one not below 60 mm Hig on room air ora low PO, on oxygen, the patient may require supple- mental oxygen with exercise 10 prevent hypoxemia during exercise, Chapter (0 presents a method of assessing the degree of hypoxemia when patients are receiving supplemen- tal oxygen Other respiratory treatments (e.., aerosols, bronchodila- tor treatments, inspirometess) chat ate prescribed should be noted because these treatments can improve the patient's exercise performance if they are administered before exescse; however, they may ako be extremely fatiguing to the patient and may necessitate limitations on activity immediately following treatment. The necessity for the coordination of physical cherapy and respiratory treatments to optimize cechabilitation should be readity apparent. If the patient is being ventilated mechanically, the mode of ventilator ass tance, the set rate, the set volume, the peak inspiratory pres sure, the fraction of inspired oxygen, the spontaneous rate, and the like should be identified. A fall description of ventila tors is found in Chapter 13. : Surgical Procedures An understanding of specific surgical approaches and proce lures, as well as knowledge of the anatomy of the chest wall, is integral to the chart review process. Knowledge of the approach or proceslare may be helpful in defining the physical therapy diagnosis and extent of the problem and in identify- ing limitations or precautions to any therapeutic procedures being planned (see Chapter 11) Ie is important to understand the number of and place- ment of the bypass grafts as well as any complications that ‘occurred during the procedure (eg, whether a pacemaker ‘was inserted) in patients who have undergone coronary artery bypass surgery. For the patient who has undergone bypass surgery with numerous vessels requiring bypass grafts or equiting left main or lefe main equivalent bypass, one might assume that the patient was more limited in activity before surgery. With extensive disease, patients usually have more symptoms with activity and may have had cestrictions with low levels of exertion. In addition, the patient who experi- ences complications (such as a perioperative myocardial infarction or stroke) during or following the surgery usually has a slower recovery and may require increased activity supervision and may make slower progress. In the patient who has undergone pulmonary surgery, the ‘amount of lung tissue that was operated on is significant to note (eg. wedge teection, lobectomy, or pneumonectomy), as well asthe location ofthe incision. The greater the amount of lung tissue that was removed, the smaller the amount of lung space that is available (one would expect) to actively 540 SECTION 6 Cardiopulmonary Assessment and Intervention diffuse oxygen and carbon dioxide and therefore the greater the impairment in performance of activities. Other Therapeutic Regimens ‘Asa result ofthe patient's primary or secondaty diagnoses o subsequent surgical procedures, addtional therapeutic inter ventions could have an impact on the proposed treatment. Identification of these interventions (e.g. pacemaker itnplan- tation, intravenous or incraarterial deug administearion, parenteral nutrition, electrolyte replacement, ot bedcest li tations) helps the physical therapist develop an appropriate treatment plan with appropriate precautions. Electrocardiogram and Serial Monitoring “The electrocardiogtam (ECG) provides valuable information regarding the stare of the heart muscle and the shythm of the heart at the time of the ECG. The ECG is used to define previous as well as current myocardial injury, hyper” ‘trophy of the heart muscle, pericardial involvement, or delays in the generation of the depolarization impulse. Serial ECG ‘monitoring provides a historic record of the patient's cardiac injury and chythm disturbances and allows the correlation ‘of the history of rhythm disturbances with changes in medi- ‘ations or medical seats. ECGs do not predict the furure and cannot give medical information of coronary anatomy. Details of the BCG and rhythm disturbances are discussed in Chapter 9, Pulmonary Function Tests ‘A pulmonary funetion rest (PFT) is an essential component of the assessment process because abnormal PETS indicate the effects of the pathologic condition and may provide clues regarding the patient’s motivation. Measurement of PETS is done via spicometry. PFTs can measure static and dynamic properties of the chest and lungs as well as gas exchange. Static measurements assess the ung volumes and capacities (eg. tidal volume, vital eapacity, inspiratory reserve volume) ‘and determine mechanical abnormalities, whereas dynamic measurements provide data on the flow rates of air moving in and out of the lungs. The dynamic properties reflect the nonelastic components of the pulmonary system and include the forced expiratory flows and volumes Values for PETS are used primarily to identify a baseline of pulmonary dysfunction as well as to follow the progres: sion of altered respiratory mechanics in chronic lung and musculoskeletal diseases. Chapter 10 explains PFTS in greater detail. Values for PFTs may be described as abnormal owing to the static values (volumes and capacities), the dynamic values (low volumes and rates), or both, When patients demon strate decreased volumes ancl capacities, they are exhibiting restrictive lung dysfunction. They therefore have less lung space for active diffusion of oxygen into the circulatory system and carbon dioxide out of the systera. Patients with clecreased dynamic values often have limitations on exercgg owing to an inability co actively move large volumes of aig rapidly. Teeatment planning reyuites modifications, possibly including supplemental oxygen for patients with extremely low lung volumes or bronchodilator medication before exer- cise for patients with dleereased low rates or volumes. Arterial Blood Gases Arcerial blood gases are a measurement of the acid-base and oxygenation status of patients via arterial blood sampling Blood gas determinations can identify the effectiveness of a treatment designed to improve airway clearance and ventila- tion. Therefore, serial arterial blood gases are often measured to provide feedback on the therapeutic regimen (© the tedical personnel. Arterial blood gases are discussed in greater detail in Chapter 10. Cardiac Catheterization Data Cardiac catheterization, which is an invasive diagnostic pro- cedure, provides information about the anatomy of the core- nary arteries and can provide a dynamic assessment of the cardiac muscle, In addition, information on hemodynamic measurement (642 estimates of ejection fraction or systolic tnd diastolic pressures) a8 well as valvular function can be obtained. Cardiac catheterizations are performed to visualize the cardiac dysfunction and to asist in the decision-making process regarding medical versus surgical management. Repeat cardiac catheterizations also provide information on the progression of, in rare cases, regression of coronary disease of valvular dysfunction. See Chapter 8 for more detailed information. Vital Signs Daily eecordings of vital signs are often kept in the graphics section of the chart. Vital signs such as hear rate, temper” ture, blood pressure, and respiration are important to review for trends as well as forthe establishment of a baseline, For ‘example, pulmonary patients with infection who are being ‘monitored for improvement can be followed by checking temperature and in some cases respirations and heart ate Hypertension and treatment for hypertension can be monk toted daly by viewing the blood pressure recontings (keeping in mind that chese have been recorded at rest and usually ia the supine position) Hospital Course A thorough review of the medical record, including pH cians’ and other caregivers’ notes, and the order sheets showy feveal pertinent information regarding the pacient’s cise ‘course since admission. For example, patients with S70" Complications within the fst 4 days ofa myocardial it tion have a higher incidence of later serious complication death, Criteria for a complicated pestimyocardial inf ital couse as defined by MeNeer and coworkers include Yalow rriculae tachycardia and ibellacion L Neal dutcer or bilan | pesistent sinus tachycardia (more than 100 beats per mite) FPesstent systolic hypotension (lower chan 90 mm Hg) F ¢ plmonary edema 4 Candiogenic shock iF pessstent angina or extension of infarction Parients who are characterized as “uncomplicated” have icantly lower morbidity and mortality rates following ier initial cardiac events. A prolonged or complicated hos- ial course can affect an individual's activity progression Fring co the effects of inactivity of bedeest. } sutritional Intake entifying nutvtional intake is especially important in indi ‘duals who are under or over-weight, yet all patients should evaluated for intake during the time of rehabilitation. “Patient may be receiving enteral (providing food through, tube in nose, stomach, or intestine) oF parenteral (intrave- | nus; bypassing eating and digestion) feedings or simply by ‘mouth. Ifthe patient is feeding himself or herself, then nutti “tonal intake needs to be verified by interview with patient | ind family as to how well the patient is eating. Without | groper incake of carbolylates an proteins, the patient may [be limited in exercise performance. Occupational History Hentifying the type of work the patient currently performs allows forthe setting of realistic goals and for developing a lan for reture to work, if possible. For example, a patient ‘who has experienced a massive complicated myocanlial infrtion may not be an appropriate candidate for returning toa job requiring heavy lifting and may need & refercal for vocational rehabilitation. The earlier the referral is made, the less the chance of financial or emotional distress. In ‘xkltion, if patient requires job modifications or will be delayed in returning to work, referrals can be made to appro- Priate team members to assist the employer in making the ‘changes necessary ot 10 assist the patient with financial planning. Home Environment and Family Situation AA supportive family is important «o the success of the reha- biliation of any patient. A support system can improve a patients ability to respond to disease, whereas @ negative home enviconment can deter the patient’ rehabilitation.® In aition, ifthe patient requires a great deal of care, the fam: ‘ys ability to supply this care and its financial resources should be assessed. Early assessment of the family situation and home environment as well as involvement of the family CHAPTER %6 Examination and Assessment Procedures 541 in the patient's rehabilitation provides for optimal transition to home. Interview with the Patient and the Family ‘After a thorough chart review, the interview with the patient and the family is the next step in the physical therapist’ initial evaluation. The purpose of this interview isto gather important information about the patient's present complaint, history of medical problems, report of symptoms, risk factors, perception and unverstanding of the problem, family situa- tion, readiness to learn, and goals for rehabilitation (both cccupational and leisure) Important components of the interview are the establish: iment of effective communication and rapport with the patient and family. Simple, open-encled questions using lar fuage easily understood by the patient and family should elicit che answers needed. For example, the therapist might ask, “What did your discomfort fet like when you were admitted to the hospital” or “How tong have you had this breathing problem” Listening is essential for learning about the patiene's problems, as well as che patients understanding ‘of and reaction to them. The therapist must remember that 4 patient with pulmonary dysfunction may have difficulty with phonation owing to shortness of breath and may have to take breaths frequently between words. Table 16-2 pro- vides some sample descriptors and questions for assessing cardiac symptoms. ‘Yabole 15-2 Differentiation of Nonanginal Discomforts from Angina (Chest Wall Pain) Stable Angina Nitroglycerin generally has no elfect Occurs any time; lasts for hours Relieved by nitroglycerin (30 sec to I min) (Comes on at the same heart rate and blood pressure and is relieved by rest (lasts only a few minutes) ‘Not palpable Muscle soreness, joint soreness, evoked by palpation or deep breaths Associated wich feelings of | Minimal additional doom, cold sweats, symptoms shortness of breath Often seen with ST-segment No ST-segment depression, depression From inwin St, Techn 15 Cardiopulmonary Physical Therapy. 2nd ed St Lous, 40, Mosby. 1950, 5a2 SECTION 6 Cardiopulmonary Assessment and Intervention “The systems review sa brief examination ofall systems chat would affect the ability ofthe patient to “initiate, sustain, and ‘modify purposeful movement for the performance of actions, tasks or activities chat are important for function” (p. 34).! “The systems review is limited examination performedl prior to the full examination and used as a screening of all the ‘major systems. The systems review includes the assessment of the following > Communication ability, affect, cognition, language, and learning syle 2 The cardiovascular and pulmonary systems, with an ‘examination of the heart rte, respiratory rate, blood pressure, and presence of edema ° The musculoskeletal system, with an examination of gross symmetry, gross range of motion, gross strength, height, and weight > The neuromuscular system, including an examination of gross movement involving balance, gait, lacomotion, ‘tansfers, and transition as well as motor control and motor learning © The incegument system, including examination of pliabilicy (texture), presence of sear formation, skin color, and skin integrity “The results of che systems review should be documented in the chart. Following the systems review the therapist is able to utilize an extensive bartery of tests ancl measures to further define limitations or problets ‘The rest ofthe physical examination requites the physical therapist co use select tests and measures that are appropriate to examine the impairments and functional limications ofthe patient (Box 16-1) In patients with cardiopulmonary dysfunction, the skills of inspection, palpation, percussion, auscultation, and acti ity assessment are the most common procedures utilized to assess the impairments and funetional limitations, 50 these are the ones that will be discussed in chis chapter. These components are found under the categories aetobic capacity! endurance, circulation, and ventilation and tespiration/gas exchange. After the entire assessment is performed, docu- mentation of the findings should be made ofall components that were examined. Physical Examination ‘The physical examination is the third step in the initial evaluation of the patient. Prior to the full examination, a systems review should be performed on all patients. inspection Inspection (observation) is a key component in the assess- ‘ment of any patient, but it is extremely important in patients with cardiopulmonary dysfunction, The patient's physical appearance may change slightly as the clinical stare changes. Box 16-1 Guide Categories for Tests and Measures > Aerobic capacity/endurance > Anthropometric characteristics > Arousal, attention, and cognition > Assistive and adaptive devices > Circulation (arterial, venous, lymphatic) > Cranial and peripheral nerve integrity > Environmental, home, and work (job/schoolplay) barriers > Gait, locomotion, and balance » Integumentary integrity > Joint integrity and mobility * Motor function (motor control and motor learning) 9 Muscle performance (Including strength, power, and endurance) > Neuromotor development and sensory integration > Orthotic, protective, and supportive devices > Pain » Posture » Prosthetic requirements » Range of motion (including muscle length) » Reflex integrity » Selfcare and home management (including activities of daily living and instrumental activities of daly living) » Sensory integrity » Ventilation and respiration/gas exchange » Work (job/schootiplay), community, and leisure integra- tion or reintegration (including instrumental activities of daily living) from Amercan Physical Therapy Asseciaton. Guide to Physical Therapist Practice, 2nd ed, Baltrnoe, APTA, 2003 Recognition of these slight changes is essential ro the day- to-day management and therapeutic treatment of patients with cardiopulmonary dysfunction. Inspection should be per formed in a systematic manner, starting with the head and proceeding caudally (until the therapist has developed a egiee of proficiency). In addition to the general appearance, the other specific ateas that should be noted on inspection include facial expression, effort to breathe through nose ot mouth, the neck, the chest in both a resting and a dynamic situation, phonation, cough and sputum production, postute and positioning, and finally the extremities. General Appearance The patients level of consciousness, body type, posture and positioning, skin tone, and need for external monitoring OF support equipment should be considered in an assessment “general appearance.” Obviously, a patient's level of com” sciousness (eg, alert, agitated, confused, semicomatoses comatose) may have a direct impact on whether the treat- ment plan is understood. A comatose patient may requi® constant atcention for positioning and prevention of pulmo ‘nary dysfunction, whereas a confysed patient may not be able tw follow a cherapist’ instructions without help, Observation fagm during inspiration and restricts lung tissue at rest, refore creating 2 restrictive effect on the lung, [ef body type (e.g, obese, normal, eachectic) is a routine I} apect of assessment that gives an inditecr mensure of nue ‘ion and in some cases an indication of level of exercise toler: | nce. For example, a patient who is markedly obese may [demonstrate a decreased exercise tolerance and an increased [work of breathing owing to the restrictive effects of an exces- Fairly lage abdomen pushing agsint the daphragn (Fig 163). By contrast, cachectic patients may also demonstrate a decreased exercise tolerance and an increased work of breathing with exercise because of weakness from muscle |, wating. |? Body posture and position should also be assessed to deter- | mine their impact on the pulmonacy system. Kyphosis and coliosis ae wo postures tha functionally limit vital capaci ted may therfore fect exercise tolerance SSD TAA (ering ort q (ost patients with cardiopulmonary “dhsfunction cannot tolerate lying on a bed with the head flat and often are found lying either in the semi-Fowler’s posi- tion in bed (Fig. 16-5) or sitting over the side of the bed or Fina chai, Skin tone may indicate the general level of oxygenation and perfusion of the periphery, An individual who has a neral cyanotic look (bluish color most noticeably at lips {and fingernail beds) may have a low PO: and may be in need | of supplemental oxygen. CHAPTER 16 Examination and Assessment Procedures 343 Figure 16-3 Semi-Fowler’s position. Patients with cardiopul- monary dysfunction often require the head of the bed elevated. Finally, the presence of all equipment used in managing the patient, including monitoring ot support equipment, should be noted. In addition, an assessment should be made of whether the equipment is being used correctly by the patient. For example, a patient who requires supplemental oxygen may be breathing through the mouth and therefore not inhaling the oxygen appropriately. Asa result, the patient may be in a confused state, which can result in an unstable clinical situation. This patient's general appearance may be eyanotie, when in fact the most recent blood gas values recorded on the chart with the patient on the oxygen are normal. However, if the patient forgot to put the oxygen ‘mask on or happened to pull the mask off because of “feelings of suffocation” and became confused and agitated as well as, cyanotic, the acute change the therapist may note on enter ing the patient’ room may be reversed by simply observing, that the oxygen isnot being used appropriately. Quick action, 544 SECTION 6 Cardiopulmonary Assessment and Intervention Namal sine ‘mina ard retute taser | {Figure 4846 tnvasive hee “he double stopcocks are used to close off the tubing system or sample | bigod from the pat” ‘feof the pulmonary ertery catheter This same monitoring system car | be used with ar a hitoring and blood sampling, (From Oblouk OG, Hemodynamic Moni | toring. Ph tee ! 6% », Inspection Inspection (observation) is a key component in the assess» am iment of any patient, but iis excremely important in patients const, 7 Rae eae eiaecht with cardiopulmonary dysfunction. The patient’s physical nary dysfutle ‘he effects of positive pressu! appearance may change slightly as the clinical state changes. _to follow a thera ing expiration is ole ae modtidomastois snore Scalene | figure 15-2 The sternocleidomastoid muscles often hypertro- ply in chronic obstructive pulmonary disease owing to Increased work of the accessory muscles to assist with | breathing. Bvaluation of the Wack The activity of the neck musculature during breathing and the appearance of the jugular veins should be a parc of the sandard patient assessmeny deidomastoid muscle is av eee ‘eles may appear more prominent. Breathing efforts during tivity may elicie more work from the neck accessory muscles to lift the chest wall up and assist in breathing during rest, The presence of jugular venous distention should be sessed with the patient sitting or recumbent in bed with the head elevated at least 45 degrees. Jugular venous disten. tion is said to be present ifthe veins distend above the level of the clavicles, It is an indication of increased volume in the venous system and may be an early sign of right-sided heart failure (cor pulmonale) (Fig. 16-9). In addition, the Patient may have left-sided heart failure (congestive heart failure), but this distinction requires auscultation of che lungs, arterial pressure measurements, and possibly a chest tadiograph, CHAPTER 16 Examination and Assessment Procedures 345 Figure 16-9 Photograph of jugular venous distention. (From Daily Ek, Schroeder JP. Techniques in Bedside Hemodynamic Monitoring, 4th ed. St. Louis, Mosby, 1981) Evaluation of the Chest: Resting and Dynamic ‘The resting chest is evaluated for its symmetry, configuration, rib angles, and intercostal spaces and musculature. Checking symmetry between sides and comparing anteroposterior (AP) and transverse diameters provide information regarding the chronicity of the eariopulmonary dysfunction as well as any present pathologic condition. For example, a patient with chronic obstructive disease may have a hyperinflated chest, which increases the AP diameter (more barrel-like). The normal AP diameter is one half the size of the transverse diameter (measured as shoulder to shoulder). [n the chroni- cally hyperinflaced chest wall, the AP diameter may be equal to the transverse diameter (Fig, 16-10). An individual with scoliosis has asymmetry from side to side when observed from. either the front or the back. Scoliosis also rotates the lungs as the scoliotic curve progresses throughout life. In addition, an individual who undengoes thoracic surgery with a lateral incision may have developed asymmetry due to pain. and splinting or due to actual lung oF rib loss fom the surgical procedure (see Fig. 5-22). Symmetry of the chest wal is also assessed dynamically with palpation of the spinous processes, ribs, and clavicles, comparing the motion fiom side to side and from top to bottom, anteriorly, laterally, and posteriorly. Some congenital defects such as pectus excavatum (funnel chest) oF pectus carinatum (pigeon chest) are important t0 observe, although they often have litte effect on pulmonary function unless they are a severe deformity (see Figs 5-18 and 5-19). Pectus excavatum can have an impact on the cardiac function. Rib angles and intercostal spaces should be observed for abnormalities that might suggest the presence of chronic disease. Normally, rib angles measure less than 90 degrees (Fig. 16-11), and they attach to the vertebrae at approxi mately 45-degree angles. The intercostal spaces are normally 544 53 Montoro. igure 16-6 invasive hemodynamic monitoring system. The double stopcocks are used 10 Coe off the tubing systern or sample SECTION 6 Cardiopulmonary Assessment and Intervention aon on igure 165, eae Mera than connect 0 the dtl port of the pulmonary artery catheter. This Sas TT Ae ‘system can be used with an arterial catheter for continuous-pressure moni toring, Philadelphia, Saunders, 1987.) by che cherapist may solve this unstable clinical situation. In addition, the use ofa cardiac monitor, pulmonary artery cath tet, of intraaottic balloon pump indicates a more seriously ill patient who may have rhythm or hemodynamic distur: bances (Fig. 16-6) Facial Characieristics Facial expeession and effort to breathe are two characteristics that can be observed easily; both give important information for the clinical evaluation of the patient. Facial expressions of distress or fatigue may indicate a need for change in the therapeutic treatment. Facial signs of distress include nasal flaring, sweating, paleness, and focused, or enlarged pupils ‘The effort to breathe can be evaluated not only by the ficial ‘expression of discres but also by the degree of work put forth from the musculature of the face and neck and the move- rent of the lips to breathe. Pursed-lip breathing isa clinical sign of chronic obstructive lung disease, is performed to alle~ vate the trapping of air in the lungs and t0 improve gas ‘exchange, and is characterized by the patient breathing out fgainst lips that are mostly closed and shaped in a cicular fashion (Fig. 16-7) Torin and blood sampling. (From Oblouk DG. Hemodynamic Monk Figure 16-7 Demonstration of pursedip breathing and te effects in patients with emphysema, The weakened bronch Sirways are Kept open by the effects of positive pressure ‘Greated by the pursed lips during expiration. CHAPT! ynocledomastots [ muscle | Seaere | igure 16-2 The sternocleidomastoid muscles often hypertro- Fay in chronic obstructive pulmonary disease owing to Pipceased work of the accessory muscles to assist with “reathing Evaluation of the Meck The activity of the neck musculature during breathing and ‘the appearance of the juguli r 1e L:atandard patient assessment deidomastoid muscle is a very important accessory respira’ taty muscle that often hypertrophies when used excessively i . ecause of a chronic typically assurned improve the efficiency of the breathing effort, the sterno- dhring rest ‘The presence of jugular venous distention should be the head elevated at least 45 degrees. Jugular venous disten- tion is said to be present if the veins distend above the level of the clavicles. [t is an indication of increased volume in the venous system and may be an early sign of right-sided hheatt failure (cor pulmonale) (Fig. 16-9). In addition, the Patient may have left-sided heart failure (congestive heart lungs, arterial pressure measurements, and possibly a chest ‘radiograph. 16 Examination and Assessment Procedures 54s ‘igure 16-9 Photograph of jugular venous distention. (From Dally Ek, Schroeder JP. Techniques in Bedside Hemodynamic Monitoring, 4th ed. St. Louis, Mosby, 1981.) it: Resting and valuation of the Ci ‘ing symmetry fes and comparing anteroposterior (AP) nd wansverse diameters provide information regarding the chronicity of the cardiopulmonary dysfunction as well as any present pathologic condition. For example, a patient with chronic obstructive disease may have 4 (Gio Heel) The normal AP diameter is one half the size of the transverse diameter (measured as shoulder to shoulder). In the chroni- cally hyerintated chest wall the AP diameter may be equal to the transverse diameter (Fig. 16-10). An individual with aap ‘asymmetry from side to side when observed from either the front or the back. Scoliosis also rotates the lungs as the scoliotic cuve progresses throughout life. In addition, incision may have Jolene i ED and splinting or de to actual lung of rb loss from che surgical procedure (sce Fig. 5-22). Symmetry of the chest wall is also ascesed dyramiclly with palpation of the spinous proces ribs and clavicle, comparing the motion from side to side ana from top eo bottom antec, Inter, and poster chest) or pectus carinatum (pigeon chest) are important to bere, although they often have litle eect on pulmonary faction unless they area severe deformity (se Figs 5-18 and 5-19). Pectuss excavatum can have an impact on the cardiac disease. Normally, rib angles measure less than 90 degrees (Fig, 16-11), and they attach to che vertebrae at approxi mately 45-degree angles. The intercostal spaces are normally 546 SECTION 6 Cardiopulmonary Assessment and Intervention | . 7 ‘able 16-3 Respiratory Rates for Infants Th ; \ Adults at i | 4 } ee . — ¢ ) : aspirntry Rates La Age {BresissMinutey } [nfant: Birth-1 year 30-60 \ ‘Toddler 1-3 years 440 \ Preschooler 3-6 years 2234 | Elementary school age 6-12 years 18-30 j ‘Adolescent 12-18 years 16 } Ale 18+ years 12-29 | = ———_ i antsiar — Postitoe apa Paee intercostals work harder than normal when theie conti. K 8 tion to normal resting or exercise breathing is increased, Figues 16-10 A, A normal anteroposterior (AP) diameter. B, The increased AP diameter in a chronically hyperinflated i chest. ib angles = 00° WZ orca = #5 \ 1 Oraphragm A B Figuee 15-17 Rib angles. A, Normal: measuring less than 90 degrees and attaching at the vertebrae at approximately a 45-degree angle. 8, Abnormal: rib angles greater than 90 degrees and attaching to the vertebrae with angles greater ‘than 45 degrees in the hyperinflated chest. Also note that the position of the diaphragm is flattened. broader posteriorly than anteriorly, but chronic hyperinfla- tion causes nsequent increased stretch is placed on the diaphragm muscle, and ic adapts by becoming flatter and thus less effective (see Fig. 16-11). ‘Other respiratory accessory muscles may hypertrophy 3s 1 result of chronic obstructive pulmonary disease because of the demand placed on them owing to the diminished capac- ity of the diaphragm muscle. The scalenes, trapezius, and Ultimately, the muscles make adaptive changes to the increased workloads by becoming hypertrophied Clinical Tip Patents with rigid chest walls or the diagnosis of difuse pulmonary fibrosis usually demonstrate a complete lack of lateral costal expan- son, Therefore, the chest wall goes up and down, but there is no outward expansion, Just as the resting chest wall must be evaluated, so must the dynamic or moving chest wall. Observations of breathing patterns, rates (Table 16-3), inspiratory to expiratory ratio, and syininetry of chest wall motion must all be made. Abnor- ‘mal breathing patterns should be noted with descriptive ter rminology, as is presented in Table 16-4. The normal adult respiratory rate is 10 t0 20 breaths per minute and can be assessed by counting the respirations for 1 full minute Observation and palpation of the moving chest ate the ree" ‘ommended methods, but one problem with assessing the respiratory rate is the fact that patients are often aware that respirations are being counted, and therefore they may sub- consciously alter the rate. ‘The ratio of inspiration to expiration during the normal breathing cyele is an important consieration, The normal inspiration-to-expiration ratio is 1:2; however, in individuals with chronic obstructive pulmonary

    You might also like