Medical Conditions I-DPTR 5301 Comprehensive Skills Outline I. There will be several case scenarios for the competency. II. Each student will have 15 minutes for the exam and 5 minutes to receive feedback from the instructor – 20 min total per student. III. When you draw a case scenario, you will be asked to explain and perform the examination and/or intervention techniques as outlined in the case. IV. The rubric will provides an “overview” of the grading that will be used for the competency (see page 2-4). V. For percussion/postural drainage, the instructor will tell you the diagnosis and area of the lung which needs to be addressed. You will be expected to assess breath sounds and “diagnostic” percussion before your intervention and after your intervention as indicated by the case. VI. For each scenario where the stethoscope is needed, you will be expected to “listen” with the diaphragm (breath sounds and normal heart sounds) and the bell (abnormal heart sounds). VII. For BP, you will be expected to perform the technique “by the book” – see below: assess the radial pulse and determine the radial occlusion pressure; deflate the cuff fully, identify the brachial pulse and then re-inflate the cuff to 30 mm Hg above the point where the radial pulse was occluded. Deflate the cuff in a controlled manner and determine the BP. Repeat if necessary (wait 1-2min btw) 1
Transcript
Medical Conditions I-DPTR 5301Comprehensive Skills Outline
I. There will be several case scenarios for the competency.
II. Each student will have 15 minutes for the exam and 5 minutes to receive feedback from the instructor – 20 min total per student.
III. When you draw a case scenario, you will be asked to explain and perform the examination and/or intervention techniques as outlined in the case.
IV. The rubric will provides an “overview” of the grading that will be used for the competency (see page 2-4).
V. For percussion/postural drainage, the instructor will tell you the diagnosis and area of the lung which needs to be addressed. You will be expected to assess breath sounds and “diagnostic” percussion before your intervention and after your intervention as indicated by the case.
VI. For each scenario where the stethoscope is needed, you will be expected to “listen” with the diaphragm (breath sounds and normal heart sounds) and the bell (abnormal heart sounds).
VII. For BP, you will be expected to perform the technique “by the book” – see below: assess the radial pulse and determine the radial occlusion pressure; deflate the cuff fully, identify the brachial pulse and then re-inflate the cuff to 30 mm Hg above the point where the radial pulse was occluded. Deflate the cuff in a controlled manner and determine the BP. Repeat if necessary (wait 1-2min btw)
VIII. For cough or breathing techniques, your instructor will tell you which technique she would like for you to perform so be prepared to demonstrate any of them.
IX. The scenarios can be either inpatient or outpatient so please practice with having your partner in gowns or in an outpatient setting where a patient may be wearing a tank top/jog bra.
X. We will use the dual stethoscopes for BP, heart and lung sounds so please practice with these. They are in 3400 in the cabinet beside the sink, which should be unlocked. If you have problems accessing the stethoscopes, please let me know.
XI. Please wear “lab attire” since access to the chest wall/ thorax is necessary
XII. Please bring a watch with a second hand which allows you to assess HR and RR.
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Example of Grading Rubric General – Communication1. ______ Introduces self to patient 2. ______ Explains overview of encounter 3. ______ Obtains Patient Consent 4. ______ Uses patient appropriate language
General - Positions and drapes the patient as needed1. ______ Maintains modesty of patient 2. ______ Appropriate positioning 3. ______ Makes area of body available for examination/intervention
Breath Sounds1._______ Knows to use diaphragm directly on skin2._______Student is systematic and uses proper anatomical positions – e.g.: auscultates at least 1 spot for each lobe bilaterally; listens top to bottom & left to right for comparison Auscultation
o Listening Techniques/ Procedures: Sit patient up; roll patient – don’t just listen for the convenient sounds Breathe deep through mouth Stethoscope on skin Systematic comparison of L and R, and all lobes (goal is to auscultate at least
3-4 spots looking for SYMMETRY BILATERALLY)
4._______Listens at each spot, full cycle of inspiration & expiration5._______Can explain normal breath sounds (bronchial (tubular/ tracheal); bronchovesicular; and vesicular) and knows where each should usually be auscultated
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6. ______ Can explain abnormal breath sounds (e.g.: crackles, wheezing) particularly in the patient scenario provided (e.g.: surgical patient versus hypersecretion of mucus versus pneumonia …etc.).
o Tracheal/Bronchial/Tubular BS
Over Trachea Loud, high pitched, harsh E>I w/ short pause Heart in other location = abnormal (lung = consolidation (PNA))
o Bronchovesicular BS
Sternum, scapula, anterior RUL I=E duration & loudness, no pause More muffled than bronchial
o Vesicular BS
Lung periphery I > E Medium pitch and loudness
o Abnormal Breath sounds Bronchial or bronchovesicular in vesicular or more peripheral area
consolidation, fluid Fluid transmits better than air
Wheeze Hear on expiration Smaller airways = high pitched, larger = low pitched Caused by narrowed airways from secretions, edema, bronchospasm
(airway collapsing when it should be open) Crackles
Discontinuous notes “bubbling” “pop” “fizz” Hear on inspiration Large airways = low pitch = “coarse”, small = high pitch =
“fine/Velcro” Diminished or absent BS
Hyperinflation (air trapping), air/fluid/blood between lung and chest wall, airway blockage (mucus, tumor, foreign body), obesity
Other info…
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o Normal I:E ratio = 1:2, obstructive = 1:3 or greatero Breath patterns
Chyne-Stokes breathing: abnormal pattern w/ oscillation of ventilation between apnea and tachypnea w/ crescendo-decrescendo pattern in depth of respiration (HF, CVA, TBI, brain tumor)
Kussmaul: consistent very deep breathing pattern at normal or increased rate (severe metabolic acidosis, form of hyperventilation)
o Fremitis Tactile Fremitis = palpable vibration produced during breathing cause by partial airway obstruction
Mucus Secretions in airway Bronchial hyperreactivity/constriction, tumor
Heart Sounds1.________Knows four locations (Aortic; Pulmonic; Tricuspid; Mitral)
(1) Aortic 2nd right ICS, right sternal border(2) Pulmonic 2nd left ICS, left sternal border(3) Tricuspid 5th left ICS, left sternal border(4) Mitral 5th left ICS, mid clavicular line
2.________Uses diaphragm for S1, S2; bell for abnormal heart sounds (S3; S4; murmurs)3.________Can explain what causes S1, S2
S1 = closure of AV valve S2 = closure of atrial semilunar valve
4.________Can explain what causes S3 S3: CHF – early diastolic sound = after S2 preceding S1
o S3 = HEART FAILURE (if managed well won’t hear this)o Low compliance of ventricles – S3 caused by crashing of blood into ventricles
S4: s/p MI; HTNo S4 Happens very very late in diastole (just before S1) o Turbulence in atrium causing swishing but still caused by decreased compliance of the
ventricles
Blood Pressure:1. _______ Assess the radial pulse and determine the radial occlusion pressure2.________ Deflate the cuff fully, identify the brachial pulse and then re-inflate the cuff to 20-30 mm Hg above the point where the radial pulse was occluded. 3. _______ Positions arm at level of heart & deflates the cuff in a controlled manner to determine the BP. 4.________Repeat if necessary
Check bilaterally, only 1 carotid at a time.2._______Knows to extend time of palpation due to irregularity of rhythm if assessing pulse rate
If irregular must assess apical pulse, and must assess for longer duration (30s-1min)3. _______Can describe “quality” of pulse (regular/ irregular; strong, normal, thread)
• (usually fatal) = hole in lung and there is no place for that air to go – no external injury, so air escapes from lung into interpleural space (disrupts pressure induced cardiac filling (R atrium, etc.)
Airway Clearance Techniques (ACT) - Postural drainage, chest wall percussion & vibration 1._______Student can explain rational behind positioning and ACT
Each position requires > 5min2._______Demonstrates proper body mechanics for chest wall percussion (therapeutic): cupped hands (no slapping), primary motion from elbows and wrists; watch your back! Uses towel layer or sheet or shirt- do not percuss directly on patient’s skin
• performed throughout whole respiratory cycle – inspiration and expiration • Perform for at least 5min
(increase in intracranial pressure), consider pulmonary embolism, consider recent incision for local contraindication
3. _______Demonstrates proper body mechanics for vibration: as vertical as possible over patient, get feedback from patient (i.e. have the patient say “eeeee”) when doing technique
• Performed only on expiration • Deep breath, hold for ~2sec, say “Eeeeee” on expiration as PT vibrates. • Continue until remove secretions (decrease or remove crackles), or patient can no longer
tolerate. (4-5 breaths) Creates external pressure and vibratory force through lungs to airways to promote
movement of secretion
4. ______ Can describe and perform alternative interventions to assist with airway clearance (deep breathing/ incentive spirometry (role: open alveoli via pores of cone/lamberts canals); assisted cough techniques; lateral costal breathing; therapeutic exercises (UE/ LE/ mobilization …etc.)
Huff Cough Step 1: Controlled (diaphragm) breathing through nose x 2-3 breaths
One hand on upper and one hand on lower chest, assume/feel normal breathing Abdomen expansion Can provide pressure to thorax to teach.
Step 2: Hold breath x 2-3 seconds (inspiratory hold) Step 3: Forceful expiration with “open glottis”
Max expiratory flow = max airway clearance Active Cycle of Breathing (ACB)
o Step 1: Controlled (diaphragm) breathing through nose x 2-3 breathso Step 2: Deep breathing through the nose followed by a breath hold x 2-3 seconds (inspiratory
hold)o Step 3: Huffingo Step 4: Repeato Hazards
Worsening SOB, hopoxemia, pain/injury to chest/spine, dysrhythmia, nausea/vomiting, bronchospasm
Providing some pressure upward/inward (scooping) abdomen on expiration, can help activate diaphragm (provides stretch)
Assisted Cough Techniques o Heimlich Cough Assist/ “Quad” cough
Hand distal to xiphoid process but superior to umbilicus Coordinate with breathing pattern – “thrust” with onset of expiration/cough
Costophrenic o Hands on costophrenic angles of lower ribs (lateral)o Follow breathing pattern
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o As patient is beginning cough, apply pressure downward and medially Increasing abdominal content pressure.
Indications/Goals for Airway Clearance Incications
Goalso Prevent accumulation, improve mobilization of secretionso Improve breathing through relaxationo Reduce symptoms of dyspneao Improve CP Ex tolerance
Breathing Exercises and Breathing Retraining1. ______ Can describe and perform breathing exercises including diaphragm breathing, deep breathing/ incentive spirometry; lateral costal breathing; segmental breathing2. ______ Can describe and perform breathing retraining strategies including diagphram breathing combined with progressive postures/ mobilization – pacing of activities; pursed lip breathing 1. Facilitation of diaphragm
Lateral costal: place hands on lower ribs, laterallya. Use hands and quick stretch to promote breathing in a certain regionb. Ex: atelectasis – want to augment airflow in this region
Segmental: place hands over desired lung region – specific region
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o If person sitting up can use your body as the “table top” laterallyo Not resisting on inhalation. o Apply quick stretch on max expiration
Ask patient to breathe into my hands – providing biofeedback. a. Don’t remove hand placement b/c want to provide that feedback
Add PNF techniques such as “quick stretch”
Cardiac &/ or Pulmonary Rehabilitation Principles (exercise prescription)1. ______ Student can create & implement an exercise prescription for patients/clients with primary cardiac &/or pulmonary disorders including all components: mode; intensity; frequency; duration; progression
Cardiac rehabo Exclusions
Unstable angina Class IV heart failure Uncontrolled sustained tachyarrhythmias or bradyarrhythmias Symptomatic aortic or mitral stenosis Severe pulmonary hypertension Conditions that could be aggravated by exercise: Systolic BP >200 mm Hg or Diastolic BP > 100 mm Hg Suspected myocarditis or pericarditis Recent systemic or pulmonary embolus Infectious disease processes
o Phase 1: Evaluate physiologic response to self-care/ambulation activity Goal 3-5METS HRrest + (20-30bpm)
o Phase 2: Outpatient Typical Exercise Rx = HR rest + [(0.5 to 0.85)x(HR max - HR rest)] Lifestyle change – improve CV/P fitness safely, functional
Pulmonary Rehabo Mode
Aerobic – large muscle groups, rhythmic, Inspiratory m training Strength training LE UE UE/LE isotonic
o Intensity – SYMPTOM PARAMETER %HRmax 60-90% HRmax or 50-85% VO2max RPE
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High intensity (start 60% goal > 80% peak work rate)o Duration
Goal 30-40min continuously Intervals
o Frequency Goal: 3-5x/week If reduced duration/intensity increase frequency
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