Transcript Chest Assessment - NAU jan.ucc.nau.edu web server
Chest Assessment Read through the chart for past medical history and reasons for the present admission. Is the present admission for some other cause other than cardiopulmonary or is this a readmission for a long standing chronic condition ? Read the psychosocial history patient’s age marital status supportive family (SW’s report) will there be at-home care or will it involve some level of postacute institutional care ? Look at the x-ray results : Diffuse spider webbing ? Egg-shell calcifications present ? Is the cardiac image obscured ? Are there spots on the lungs ? Are fractures present ? Fluid lines present ? Left Pneumothorax CWP - Black Lung Flail Chest Cancer - Tumor In Right Lung Read the pulmonary function test results chronic obstructive lung disease restrictive lung disease occupational lung disease Chronic Obstructive Disease asthma bronchitis emphysema bronchiectasis Restrictive Lung Disease sarcoidosis tuberculosis pneumonia ARDS IRDS Valley Fever Occupational Lung Disease psiticosis byssinosis - white lung CWP - black lung silicosis asbestosis pidgeon breeders disease Read the blood gas report Is the patient acidotic ? Is the patient alkalotic ? Has the patient metabolically compensated ? Normal Blood Gas Values pH = 7.35 - 7.45 PO2 = 80 - 100 mm Hg PCO2 = 36 - 44 mm Hg HCO3 = 22 - 26 mEq/L Read the bacteriology lab report for any infective organisms gram positive bacteria gram negative bacteria yeast infections HIV + Gram Positive Bacteria : staphylococcus - osteomyelitis streptococcus - septicemia clostridium - gangrene Gram Negative Bacteria salmonella - food poisoning shigella - dysentery klebsiella - pneumonia pseudomonas - deep infections Hemaglobin & Hematocrit okay ? Hemaglobin : females - 13-14 g/dl males - 15 -16 g/dl Hematocrit : females - 32 - 42 % males - 42 - 52 % Briefly review the reports by the various services : respiratory therapy physician’s progress notes social worker’s report nurses notes Patient Evaluation Smoking History ? S.O.B. & when did it start ? Occupation ? Return to work ? Is the patient ambulatory ? Do they use portable oxygen ? Are there positions of comfort ? Talk Test Physical Exam Auscultate the lungs : adventitious sounds rales rhonchi pleural friction rub stridor Chest measurements - bilateral excursion - rib flare ? - ant/post movement of the chest ? Breathing patterns See-Saw breathing diaphragmatic breathing apical breathing Double cough ? Productive cough ? Quantity of sputum Color of sputum Vocal fremitus ? Patient’s color ? CO2 narcosis - redness of skin hypoxemia - cyanosis - blue cast Mediate percussion Surgical scars ? Chest deformations ? Pectus excavatum Pectus carinatum cavitations barrel chest Rate & depth of respiration Dyspnic ? Tachypnic ? Nasal flaring ? Accessory muscle use ? Can the patient perform self-care ? Can they roll in bed and come to sitting ? Can they transfer into a chair ? Can they walk in the room or out into the hall ? Do they need supplemental oxygen at rest and during ADL’s or during exercise ? Does the patient have pitting edema in the lower extremities ? 1+, 2+, 3+, 4+ CHF renal failure metastatic cancer Patient Case Study # 1 82 y/o Caucasian female Admitted for observation to EROU (23-hour stay): falling c/o of pain in chest and hip PT consult : evaluation for level of medical care Social History Living alone in a rented apt. at Meridian Point - minor assisted living contract Because of falling hx., Meridian Point would take her into their full assisted living units if she was admitted for 3 days at FMC Family lives in Flagstaff, Az. Family expressing reluctance about having her move in with them for companion care Medical History Fractured radius in Jan, 1999 Fractured right femur in August, 1994 Bilateral mastectomy - Cancer - 1980 Pneumonia - 1980, 1990, 1996 Negative for diabetes Medical Findings CT scan of thorax, pelvis WNL CT scan of brain showed atrophy - WNL X-Ray of chest showed some diffuse cloudiness in L > R - no masses Physical Therapy Exam ROM - WNL for all extremities Strength - 4/5 for age Gait - 125 ft without LOB w/ FWW Transfers - SBA ---> min assist Orientation - 3/3 Oximetry - SaO2 - 86% on 2 L/min as per nasal cannula Blood Pressure - 156/88 Heart Rate - 98 bpm Breathing - diaphragmatic Resp. rate - 18/min & shallow Talk test - normal No vocal fremitus present Fever - 102° F Subjective Symptoms : “I feel fine - I want to go home.” Auscultation Of Thorax mild crackles - left lingula, R middle lobe medium crackles - bilateral anterior, lateral and posterior basilar BP segments all other BP segments clear Recommendations ? Discharge to home with family for 24-hour companion care ? Admission to hospital for 3 days and then to assisted living at Meridian Point ? Back to Meridian Point and independent apartment living ? Patient Case Study # 2 51 year old Native American female Admitted to the hospital for : inebriated pedestrian vs car fractured right and left tibia and fibula in the distal 1/3 of both LE’s fractured C3-C4 stable and nondisplaced multiple abrasions and lacerations closed head injury aspiration pneumonia Physical Therapy Order : Mobilize the patient - NWB on BLE’s Functional activities Social History Lives with her daughter in Tolani Lake, Az. She herds cattle on a small ranch Has a significant ETOH hx. Has a significant psychiatric hx. Has a significant spouse abuse hx. Is now divorced Medical History : Repeated ETOH detox admissions to Aspen Hills - ‘92, ‘93, ‘95, ‘98 Significant for appendicitis in ‘84 Significant for hypertension Significant for COPD (asthma) Significant for hyperlipidemia Significant for CAD - report of occasional angina on hard exertion Physical Therapy Findings Full ROM in all uneffected joints and extremities Strength is WNL in BUE’s (5/5) BLE’s not tested Bronchovesicular breath sounds in the bilateral posterior and lateral basilar bronchopulmonary segments of the bilateral lower lobes A Monarch UE GXT was given physical work capacity was Fair BP at rest = 150/92 BP at SLGXT = 212/100 HR at rest = 78 BPM HR at SLGXT = 168 BPM Max METs obtained = 8.5 Functional Mobility sitting balance = good bed mobility = good ADL’s = good with self care Recommendations ?