ASSESSMENT OF RESPIRATORY SYSTEM

                                                                ASSESSMENT          

  OF            

RESPIRATORY SYSTEM

RESPIRATORY SYSTEM

Patient Profile

    Name of client :        

                     Age  :        

                    Sex   :        

               I P No.   :        

                  Ward :        

                   Unit   :        

    Marital Status  :        

                   Educational Qualification        :        

                                               Religion       :        

                                      Occupation :        

                                          Income    :        

                                           Address  :        

                                                                  

                                    Admitted on  :        

                                 Source of data :        

                                            Diagnosis        :        

HISTORY COLLECTION :

â    CHIEF COMPAINTS

â    CURRENT HEALTH STATUS

â    PAST HEALTH HISTORY

CURRENT SYMPTOMS:

µ  Chief Complaint:

ø   Dysnoea: Shortness of breath / Tightness / being winded / breathless.

Dysnoea Scale

è  Visual Analogue Scale:

   Shortness of breath as bad as can be

                                      100mm

                                       No shortness of breath  

æ  Objective Sign:

Criteria:

Rise of the clavicle during inspiration

       ABSENT        =         not detected

       MILD              =          Seen but not pronounced

       SEVERE         =          Pronounced

æ  Subjective Symptoms:  ( Circle Answer)

On a scale of 0-4

            No Distress – 0

                        Much Distress – 4

Poor Appetite	0	1	2	3	4
Worn out or weak	0	1	2	3	4
Suffocation	0	1	2	3	4
Tightness	0	1	2	3	4
Congestion	0	1	2	3	4
A feeling of panic or anxiety	0	1	2	3	4

æ  New York Heart Association Classification:

0     -           Not at all breathless

1     -           Breathlessness on heavy exercise (such as climbing two or three 

                   Floors)

2     -           Breathlessness on moderate exertion (such as climbing one floor

                   Or walking quickly)

3     -           Breathless on mild exertion (such as walking at normal speed)

4     -           Breathless on minimal exertion (such as slow walking)

5     -           Breathlessness on limited exertion (such as showering, bathing or

                   Washing)

æ  Modified Borg Category – Ratio Scale:

0	Nothing at all
0.5	Very, Very Slight
1	Very Slight
2	Slight
3	Moderate
4	Somewhat Severe
5	Severe
6
7	Very Severe
8
9	Very very severe
10	Maximal

SYMPTOM ANALYSIS:

Setting:

è  Physical :

è  Psychological

Timing:

è  Onset               :           Sudden / gradual

è  Period              :           days / weeks / month

è  Specific period of time: Morning / night

è  Client’s perception

Quantity:

è  Amount:

è  Size

è  Number

è  Extent

è  Quality: Tight / Loose /

  dry / hacking/

congested ( COUGH)

Location:

è  Aggravating Factor:

o   Environmental allergens: Dog /Cat

dander / dust mites /

mold / pollen

è  Relieving Factor: Sitting up / lying down /

        medication

è  Associated manifestations: Chills / fever/

  night sweat / Anorexia /

  weight loss / excessive fatigue /

  anxiety hoarseness

COUGH:

Beginning                  :           suddenly / gradually

Duration                    :           day / week /

                                    month

Frequency                 :

Time of day               :           Early morning / late afternoon /

night time (better /worse)

Description               :           Hacking / Dry /

hoarse / congested /

barking/ wheezy /

bubbling.

Medication / treatment:      Antitussive / codeine/

             inhalers/ rest/

            sitting up.

Stress incontinence:            Present / absent

SPUTUM PRODUCTION:

           

Color                          :           Clear / yellow/

                        green/ rusty/

                                    bloody

            Odor                           :           Foul / no odour

            Quality                       :           Watery / stringy /

                                    frothy / thick

            Quantity                     :           Teaspoon / Tablespoon / cup

            Consistency               :           Thick / thin / moderate

HEMOPTYSIS:

            Source                        :           Lungs / nose bleed / stomach

            Amount                      :           Teaspoon / tablespoon / cup

CAUSE:

Pulmonary                :          chronic bronchitis / bronchiectasis /

Pulmonary tuberculosis / cystic fibrosis /

Upper airway necrotizing granulomas /

pulmonary embolism pneumonia / lung cancer /

Lung abscess

Others                        :          Cardiovascular abnormalities / Anticoagulants /

Immunosuppressive drugs.

WHEEZING:

Time                             :         Early morning / late afternoon /

night time (better /worse)

            Alleviating Factor     :         Medication

STRIDOR:

            Changes:      

Voice character            : Present / Absent

                                    Hoarseness                    : Present / Absent

                                    Difficulty Swallowing : present / Absent

Sleeping Disorders       : Insomnia / degree of snoring /

                                          Hyper somnolence                    

CHEST PAIN

            Location:

            Duration:

            Intensity:       Pain rating scale 1 -10

            Frequency:   

 

  0         1            2            3            4           5            6            7            8         9         10

No                                                             Moderate                                                       Worst

Pain                                                             Pain                                                       Possible

                                                                                                                Pain

PAST HEALTH HISTORY:

Medical History:

            Respiratory                            :          Asthma / Bronchitis/

                                                                        Lung cancer / Tuberculosis

           

Non- respiratory                  :           Lupus / Rheumatoid arthritis

                                                                        Severe scoliosis

           

Surgical history                   :          Lobectomy / Pneumonectomy/

                                                                        Tracheostomy / Wedge resection

                                                                        Bronchoscopy

           

Medication                             :          Antibiotics / Bronchodilators /

                                                                        Cough expectorant / Cough suppressant

                                                                        Oxygen

           

Communicable diseases     :           Coryza / Tuberculosis /

                                                            Flu / AIDS

Allergies                                :           Drugs / Food /

                                                            Pets / Dust

                                                            Smoke / Perfume

                                                            Pollen

Injuries & Accidents           :           Chest trauma / near drowning

Special needs                        :           Oxygen dependent / dysnoeic

                                                            Pacer dependent / Ventilator dependent

Childhood illness                 :           Pertusis & measles / Bronchiectasis

FAMILY HEALTH HISTORY:    

Allergies:

            Alpha-antitrypsin deficiency         :          

Chronic illness:

            Asthma                                   :           Present / Absent

            Bronchiectasis                     :           Present / Absent

            Cancer                                   :           Present / Absent

            Cystic Fibrosis                     :           Present / Absent

            Emphysema                          :           Present / Absent

            Sarcoidosis                           :           Present / Absent

            TB                                           :           Present / Absent

SOCIAL HISTORY :

Alcohol               

            Amount                      :           in ounce

            Duration                    :           Days / Months / Years

            Frequency                 :           Occasionally / 

Alcohol	CAGE Questionnaire
C       =	Have you ever felt you should cut down on your alcohol intake
A       =	Have people Annoyed you by criticizing your alcohol intake
G       =	Have you ever felt guilty about your alcohol intake
E       =	Have you ever needed alcohol for an Eye opener

Drug use                                :           Heroin / Barbiturates / Cocaine

            Tobacco use                          :           Years of smoking X packs smoked per day

            Use of non tobacco products         : Specify

(Assessing readiness to quit smoking 5A’S)        

Ask about tobacco use

Advise to quit through clear personalized messages

Assess willingness to quit

Assist to quit

Arrange follow up & support

PSYCOSOCIAL HISTOPRY:

Occupation exposure:        to dust / asbestos / other toxins

Hobbies                     :          involve chemicals / heat

                                                Dust / grinding

                                                Soldering / welding

Geographic location:          Recent travel:

Environment:

                                                Living condition:

Exercise:

F = frequency of exercise

I = intensity

T = time / duration

T = type of exercise

   

REVIEW OF SYSTEM

INSPECTION :

Chest wall Configuration              :           Elliptical / Barrel Chest /

Pigeon Chest / Funnel Chest /

Thoracic kyphoscoliosis

Symmetry of Chest Wall               :           Symmetrical / Asymmetrical

Presence of superficial veins        :           Present / Absent

Coastal angle                                   :           90 Degree / > 90 Degree

Angle of the Ribs                             :           45 Degree / > 45 Degree

Intercostal Space - Retraction    :           Present / Absent

Muscles of Respiration                  :           Use of accessory muscles: Yes / No

Respiration                                      :          

Rate                                                   :           Eupnoea / Bradypnoea / Tachypnoea

Rhythm                                             :           Normal / Abnormal (Specify)

Pattern                                              :           Tachypnoeal / Bradyphoea

                                                                        Apnoea / Cheyne stoke’s

                                                                        Biot’s  /  Apneustic

                                                                        Agonal  / 

Depth                                                 :           Hyperphoea  /  Air Tapping

                                                                        Kussmals  /  Sighing /

                                                                        Shallow

Symmetry                                         :           Symmetrical  /  Paradexical /

Unilateral Expansion / Absence of Expansion

Audiblity                                           :           Audible / Not Audible

Patient position                               :           Supine / Prone /

                                                                        Upright

Mode of breathing                          :           Nosel / Mouth

                                                                        Pursed Lip breathing /

Stoma / Tracheostomy

Sputum : Color                                :           Light yellow or Clear / Mucoid

                                                                        Yellow / Green

                                                                        Rust / Blood tinged

                                                                        Black & Pink

                                                                                                           

PALPATION:

General Palpation                                     

Pulsation                               :           Present / Absent      

Masses                                   :           Present / Absent

Thoracic tenderness                        :           Present / Absent

Crepitus                                 :           Present / Absent

Thoracic excursion                                    :           Thumb separation of 3-5cm / unilateral

                                                                        Decreased / Bilateral decreased

Tactile Fremitus                             :           Buzzing / Increased

                                                                        Decreased / Absent

Tracheal Position                           :           Midline / deviated to affected side /

                                                                        Deviated to unaffected side.

Percussion                                        :

            Lung                                       :           Resonant / Hyperresonant 

Diaphragm                                       :           Dull

Rib                                                      :           Flat

Diaphagmatic Excursion              :           3-5cm / <3cm /

                                                                        High diaphragmatic level

                                   

NUTRITIONAL ASSESMENT

  A . DIET HISTORY

Ä  Follow any particular diet

Ä  Likes all foods, Especially sweets

Ä  Has strong cravings late at night for chocolate & ice cream

Ä  Eats fast food breakfast 9 AM

Ä  Usually has dinner at fancy restaurants 2-3 x per week with colleagues

Ä  Has small refrigerator on house boat

Ä  Occasional heartburn especially after fatty food intake

Ä  Gained 30 lbs in past year

Food intake history   : 24 hrs recall

B. ANTHROPOMETRIC MEASUREMENTS

Height                                              :           in cm

Weight                                             :           in kg

BMI                                                  :           Weight in Kg

                          M2

Normal limits                                 :           20 – 25

Overweight                                     :           25 - 29.9

Obese (class I)                                :           30 – 34.9

Moderately obese (class II)          :           35 – 39.9

Extremely obese (class III)           :           > 40

Ideal body weight                          :           Current weight

                                                                      ---------------------    X  100

                                                                      Ideal body weight

Mild obesity              :    20 – 40 %

Moderate obesity     :    40 – 100 %

Morbid obesity         :     > 100%

Waist Hip Ratio                             :           Waist in inches         Female  : 0.8 (normal)

                                                                       Hip in inches           Male      : 1 (normal)

                                                                     

C . LABORATORY DATA

Hematocrit                                        :           Female  :35 – 45 %

                                                                        Male     : 39 – 50  %

Hemoglobin                                      :           Female : 12 – 15 gm /dl

                                                                        Male      13 – 17 gm / dl

Lipids                                                 :

Cholesterol                                        :           < 200 Desirable; > 240: High

HDL                                                    :         <40 low / > 60 high

LDL                                                    :       < 100 – optimal

                                                                    100 – 129 near optimal

                                                                    130 – 159 borderline high                                     

160 – 189 high

> 190 very high

Triglyceride                                      :           < 150 normal

                                                                         150 -199 borderline  high

                                                                         200 – 499 High

                                                                        > 500 very high

Total Lymphocyte count                 :           1500  -  1800 cells / mm3

Albumin                                             :           3.5 – 5.0  gldl

Glucose                                              :           85 – 125 mgldl

Creatinine                                          :           0.6 – 1.2 mg %

Nitrogen balance                              :           Grams of protein eaten

                                                                        ---------------------------      - UUN +4

                                                                                         6.25

UUN               = 24 hr Urine Urea nitrogen

Normal                  = O Balance

Tissue Formation = Positive balance

                                                                        Catabolic state     = Negative balance

HEAD TO FOOT ASSESMENT

General appearance             :           Thin / Moderate built / obese

                    Height    :           in cm

                   Weight    :           in kg

Head                                                                      :

Face                            :           Symmetrical / asymmetrical

Oedema                      :           present / absent

Eye            

Eyebrow                    :           Equal distribution of hair / sparingly distributed / absent

Eyelashes                  :           Equal distribution of hair / sparingly distributed / absent

Conjunctiva              :           Pale / yellow / pink

Eyelid                         :           Able to open & close / ptosis

Pupils                                     :           PERLA

Ear            

Position                      : Above the level of outer canthus / At the level of outer canthus /  

  below the level of outer canthus

Drainage                    :           present / absent

Nostrils                      :           patent / obstructed

Septum                       :           Centre / deviated

Discharge                  :           present / absent

Mouth        

Lips                            :           Dry / moist

Gums                          :           Healthy / swollen

Odour                         :           present / absent

Throat                                    :           Normal / inflammed

Neck

Trachea                      :           Midline / deviated

Neck Muscle

Retraction                  :           present / absent

Chest

 Inspection                 :           chest movement: Symmetrical / asymmetrical

Auscultation             :           . S1 S2 heard

                                                Lung sound

Percussion                 :           Hyper resonant / resonant / dull

Palpation                   :           mass / tenderness

Upper Extremity

Rom                            :           Full / limited

Abdomen                   :

Inspection                  :           Shape / scar / lesion

Auscultation             :           Bowel sound: absent  / borborgymi

Percussion                 :           Tympany / resonant / dull  

Palpation                   :           Organomegaly / tenderness

Lower Extremity

Rom                            :           Full / limited

Capillary refill          :           < 3 Seconds / > 3 seconds

Genitalia             

External                     :           drainage / edema /

                        Inflammation / odour

                       

IMPRESSION           :