Monday, June 21, 2010

CAPSULAR PATTERN OF JOINT

Joint

Capsular Pattern

Temporomandibular

Opening

Occipitoatlanto

Extension & side flexion equally limited

Cervical Spine

Side flexion & rotations equally limited, extension

Glenohumeral

Lateral rotation, abduction, medial rotation

Sternoclavicular

Pain at extreme range of movement

Acromioclavicular

Pain at extreme range of movement

Humeroulnar

Flexion, extension

Radiohumeral

Flexion, extension, supination, pronation

Proximal Radioulnar

Supination, pronation

Distal Radioulnar

Pain at extremes of rotation

Wrist

Flexion & extension equally limited

Trapeziometacarpal

Abduction, extension

MCP and IP

Flexion, extension

Thoracic Spine

Side flexion & rotation equally limited, extension

Lumbar Spine

Side flexion & rotation equally limited, extension

SI, Symphysis Pubis, & Sacrococcygeal

Pain when joints stressed

Hip

Flexion, Abduction, medial rotation (order varies)

Knee

Flexion, extension

Tibiofibular

Pain when joint stressed

Talocrural

Plantar flexion, dorsiflexion

Subtalar (Talocalcaneal)

Limitation of varus range of movement

Midtarsal

Dorsiflexion, plantar flexion, adduction, medial rotation

First MTP

Extension, flexion

Second to Fifth MTP

Variable

IP

Flexion, extension

GENERAL CARDIO-RESPIRATORY ASSESSMENT

Adult Cardio-Respiratory Assessment


The following assessment must be completed and documented. As a complete respiratory exam includes a cardiovascular exam, these two examinations have been combined.

ASSESSMENT

History of Present Illness and Review of Systems

General

The following characteristics of each symptom should be elicited and explored:

• Onset – sudden or gradual

• Location - radiation

• Duration – frequency, chronology

• Characteristics – quality, severity

• Associated Symptoms

• Aggravating and precipitating factors

• Relieving factors

• Current situation (improving or deteriorating)

• Effects on ADLs

• Previous diagnosis of similar episodes

• Previous treatments and efficacy of

Cardinal Signs and Symptoms

In addition to the general characteristics outlined above, additional characteristics of specific symptoms should be elicited, as follows:

Cough

• Quality (e.g., dry, hacking, loose, productive)

• Severity

• Timing (e.g., at night, with exercise, in cold air, outside or inside)

• Duration: greater than 2 weeks (screen for TB)

Sputum

• Colour

• Amount (in teaspoons, tablespoons, cups)

• Consistency

• Purulence, odour, foul taste

• Time of day, worse

Hemoptysis

• Amount of blood

• Frank blood or mixed with sputum

• Association with leg pain, chest pain, shortness of breath


Shortness of Breath

• Exercise tolerance (number of stairs client can climb or distance client can walk)

• Relation to posture

• Orthopnea (number of pillows used for sleeping)

• Shortness of breath at rest

• Association with paroxysmal nocturnal dyspnea (waking up out of sleep, acutely short of breath; attack resolves within 20 to 30 minutes of sitting or standing up)

• Associated swelling of ankles or recent weight gain

Cyanosis

• Observation of blue colour of the lips or fingers (under what circumstances, when first noted, recent change in this characteristic)

Wheeze

• Timing (i.e., at rest, at night, with exercise)

Chest Pain (see table 1)

• Associated symptoms (i.e., faintness, shortness of breath, nausea)

• Relation to effort, exercise, meals, bending over

• Explore the pain carefully. Include quality, radiation, severity, timing, quality.

Fainting or Syncope

• Weakness, light-headedness, loss of consciousness

• Relation to postural changes, vertigo or neurological symptoms

Extremities

• Edema:

- site (i.e., in dependent body parts)

- relation of edema to activity or time of day

• Intermittent claudication (exercise-induced leg pain)

- distance client can walk before onset of pain related to claudication

- time needed to rest to relieve claudication

- temperature of affected tissue (warm, cool or cold)

• Tingling

• Leg cramps or pain at rest

• Presence of varicose veins

Other Associated Symptoms

• Fever

• Malaise

• Fatigue

• Night sweats

• Weight loss

• Palpitations

• Nausea and vomiting

• GI Reflux


Medical History (Specific to Cardio-respiratory Systems)

• Allergies

• Medications currently used (prescription and over the counter [e.g., angiotensin-converting enzyme (ACE) inhibitors, ß-blockers, ASA, steroids, nasal sprays and inhaled medications (puffers, antihistamines, estrogen, progesterone, diuretics, antacids, steroids, digoxin)]
• Herbal/traditional preparations

• Immunizations (e.g., pneumococcal, annual influenza)

• Disorders:

- Frequency of colds and treatment used, nasal polyps, chronic sinusitis

- Asthma, bronchitis, pneumonia, chronic obstructive pulmonary disease (COPD), tuberculosis (TB) (disease or exposure), cancer, cystic fibrosis

- Dyslipidemia, hypertension, diabetes mellitus, thyroid disorder, chronic renal disease, systemic lupus erythematosus
- Coronary artery disease, angina, myocardial infarction

- Cardiac murmurs, valvular heart disease

- Recent viral illness, history of rheumatic fever

• Seasonal allergies

• Presence of symptoms of gastro-oesphageal reflux disease (GERD)

• Admissions to hospital and/or surgery for respiratory or cardiac illness

• Date and result of last Mantoux test and chest x-ray

• Blood transfusion

Family History (Specific to Cardio-respiratory Systems)

• Others at home with similar symptoms

• Allergies, atopy

• Asthma, lung cancer, TB, cystic fibrosis

• Diabetes mellitus

• Heart disease: hypertension, ischemic coronary artery disease, MI (especially in family members < 50 years of age), sudden death from cardiac disease, dyslipidemia, hypertrophic cardiomyopathy

Personal and Social History (Specific to Cardio-respiratory Systems)

• Smoking history (number of packages/day, number of years)

• Exposure to second hand smoke, wood smoke

• Substance use – alcohol, caffeine, street drugs, including injection drugs, cocaine, steroids

• Occupational or environmental exposure to respiratory irritants (mining, forest fire fighting)

• Exposure to pets

• Crowded living conditions

• Poor personal or environmental cleanliness

• Institutional living

• Injection and inhaled drug use

• Alcohol use

• HIV risks

• Mold

• Obesity

• High stress levels (personal or occupational)


PHYSICAL ASSESSMENT

Vital Signs

• Temperature

• Pulse

• Respiratory rate

• Blood pressure

• Sp02

General Appearance

• Acutely or chronically ill

• Degree of comfort or distress

• Position to aid respiration (e.g., tripod)

• Diaphoresis

• Ability to speak a normal-length sentence without stopping to take a breath

• Colour (e.g., flushed, pale, cyanotic)

• Nutritional status (obese or emaciated)

• Hydration status

Inspection

• Colour (e.g., central cyanosis)

• Shape of chest (e.g., barrel-shaped, spinal deformities)

• Symmetry of chest movement

• Rate, rhythm and depth of respiration, respiratory distress

• Use of accessory muscles (sternocleidomastoid muscles)

• Intercostal indrawing

• Evidence of trauma

• Chest wall scars, bruising, signs of trauma

• Clubbing of the fingers

• Precordium: visible pulsations

• Jugular venous pressure

• Color of conjunctiva

• Extremeties

- Hands - edema, cyanosis, clubbing, nicotine stains, cap refill (<3 seconds)

- Feet and legs - changes in foot colour with changes in leg position (i.e., blanching with elevation, rubor with dependency), ulcers, varicose veins, edema (check sacrum if client is bedridden), colour (pigmentation, discoloration), distribution of hair

• Skin - rashes, lesions, xanthomas

Palpation

• Tracheal position (midline)

• Chest wall tenderness

• Respiratory Excursion

• Tactile fremitus

• Spinal abnormality

• Nodes (axillary, supraclavicular, cervical)

• Masses

• Subcutaneous emphysema

• Apical beat:

- PMI normally located at the fifth intercostal space, mid-clavicular line

- Assess quality and intensity of apical beat – normal, diffuse, weak, forceful, heave

- Apical beat (PMI) may be laterally displaced, which indicates cardiomegaly

• Identify and assess pulsations and thrills (palpable murmur that feels like a purr) in aortic, pulmonic, mitral and tricuspid areas, along left and right sternal borders, in epigastrium and along left anterior axillary line

• Hepatomegaly, RUQ tenderness

• Peripheral pulses

- Check for presence, rate, rhythm, amplitude and equivalence of peripheral pulses, (radial, brachial, femoral, popliteal, posterior tibial, dorsalis pedis)

- Check for synchrony of radial and femoral pulses

• Edema: pitting (rated 0 to 4) and level (how far up the feet and legs the edema extends); sacral edema

• Skin: temperature, turgor, texture

Percussion of lung fields

• Resonance

- Increased resonance over hyperinflated areas (e.g., asthma, emphysema)

- Dullness to percussion over areas of consolidation (e.g., pneumonia, pleural effusion and collapsed lung)

• Location and excursion of the diaphragm

Auscultation of lungs

• Assist client to breathe effectively

• Listen for sounds of normal air entry before trying to identify abnormal sounds

• Degree of air entry throughout the chest (should be equal)

• Quality of breath sounds (e.g., bronchial, bronchovesicular, vesicular)

• Ratio of inspiration to expiration (prolonged expiration in asthma, COPD)

• Adventitious Sounds:

- Wheezes (aka rhonchi): continuous sounds, ranging from a low-pitched snoring quality to a high-pitched musical quality, may be inspiratory or expiratory, or both, may clear with coughing, may be present only on forced expiration.

- Crackles (aka rales): discrete, crackling sounds heard on inspiration, may clear with coughing. May be fine (high-pitched, short popping sounds) or coarse (low-pitched, bubbling and gurgling sounds). Diffuse in severe pneumonia, bronchiolitis, CHF. Localized in bronchiectasis and pneumonia.

- Pleural rub: a coarse, creaking sound from pleural irritation, heard on inspiration or expiration

- Stridor: high-pitched, inspiratory, crowing sound louder in the neck.

- Pleural rub: pneumonia, effusion

- Decreased breath sounds: pneumonia, atelectasis, pleural effusion, pneumothorax

Auscultation of heart

• Listen to normal heart sounds before trying to identify murmurs. Use diaphragm of stethoscope first, then bell of stethoscope, when listening to the heart

• Auscultate at aortic, pulmonic, Erb’s point, tricuspid, and mitral. Attempt to identify:

- Rate and rhythm.

- S1 and S2 sounds and their intensity

- Added heart sounds (S3 and S4), rubs, splitting of S2

- Murmurs: determine location (where murmurs are best heard), radiation, their timing in cardiac cycle, intensity (grade; seeTable 1) and quality

• Auscultate carotid arteries, abdominal aorta, renal arteries, iliac arteries, and femoral arteries for bruits


Table 1. Grade of Heart Murmur

Grade Characteristics

I
Very quiet, barely audible
II
Quiet but audible
III
Easily heard
IV
Thrill can be felt, murmur is easily heard
V
Thrill can be felt and loud murmur can be heard with stethoscope placed lightly on chest
VI
Thrill can be felt and very loud murmur can be heard with stethoscope held close to chest wall

Associated Systems

Ear, Nose, Throat

• A complete respiratory assessment includes the ENT system.

CLINICAL REASONING AND CLINICAL JUDGMENT

The first step is to differentiate between acute respiratory distress and respiratory conditions that can be managed safely by certified practice nurses.

The following signs and symptoms require immediate referral to a physician or nurse practitioner:

• Severe dyspnea

• Unable to lay flat

• Inability to speak or fragmented speech

• Tracheal shift

• Unrelieved chest pain

• Unable to maintain Sp02 greater than > 92% on room air

• Severe increasing fatigue

• Cyanosis (central cyanosis is not detectable until SaO2 is less than 85%)

• Silent chest or crackles throughout lung fields

• Decreased level of consciousness

• Diminishing respiratory effort

• Nasal flaring or tug

• Intercostal indrawing

• Pulsus paradoxus

• Pitting edema of extremities

• Recent MI

• Recent hospitalization for Congestive Heart Failure (CHF)


DIAGNOSTIC TESTS:

• The certified practice nurse may consider the following diagnostic tests in the examination of the cardio-respiratory system to support clinical decision making:

- ECG

- Hemoglobin

- Cardiac troponins