Page 359 - ACCCN's Critical Care Nursing

336 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

relation to activities (e.g. breathlessness when dressing exposure to allergens and toxins in the work place is
or walking across a room). Ask the patient how many important information to collect because this can be
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pillows they need to sleep as this may indicate the sever- associated with a decline in lung function. Ask about
ity of any orthopnoea. If the patient becomes short of the patient’s home situation and whether they live with
breath when lying flat (orthopnoea) it can be a symptom someone with an infection or disease such as influenza
of increased blood in the pulmonary circulation due to or tuberculosis. Ask about children who are close to the
left ventricular failure, pulmonary oedema, bronchitis, patient, as innocuous viral infections in small children
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asthma or obstructive sleep apnoea. may account for severe disease in adults. Check also
A cough can be dry or wet, episodic or continuous and, whether there is a family history of cancer, heart or respi-
if exacerbated when the patient is lying flat, can imply ratory diseases.
heart failure. A cough can also be related to viral infec-
tions and allergies or it can indicate intra-thoracic disease. PHYSICAL EXAMINATION
Ask the patient if they wake during the night due to the The four activities of physical examination are inspection,
cough, how long the cough has been present and if it is palpation, percussion and auscultation. Percussion is
getting better or worse. rarely used by critical care nurses, so only the other three
Sputum production should be considered for amount, techniques are discussed here. Prior to commencing the
colour or the presence of blood. Yellow or green sputum examination, prepare the patient as best as is possible by
is typical in bacterial infection. Haemoptysis or sputum providing privacy, warmth, good light and quiet sur-
mixed with blood is a significant finding and can indicate roundings (this can be difficult to achieve in the critical
tuberculosis or lung cancer. Wheezing can indicate vocal care environment). Explain to the patient that the exami-
cord disorder or asthma. 22 nation is a standard procedure and that you will use your
eyes, hands and a stethoscope. Help the patient into a
Chest pain can result from multiple causes, therefore comfortable sitting position in the bed if possible and
appropriate assessment is essential. Chest pain that occurs have all the necessary equipment easily accessible.
during inspiration can be due to irritation or inflamma-
tion of the pleural surface. Pleural pain is experienced Inspection
mostly on one side of the chest, is knifelike in character
and occurs in pneumonia and spontaneous pneumotho- Inspection involves carefully observing the patient for
rax. The most significant chest pain occurs as a result of signs of respiratory problems. Focus on: patient position,
myocardial ischaemia, due to too little oxygen to the chest wall inspection, respiratory rate and rhythm, respi-
coronary blood vessels. This pain is termed angina pec- ratory effort, central or peripheral cyanosis and clubbing.
toris and can arise from chronic stable angina or acute Note what position appears preferable for the patient,
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myocardial infarction (see Chapter 10 for further discus- whether they look comfortable in bed, having trouble
sion). Chest pain also occurs with fractured ribs. breathing, or appear anxious. Observe from head to toe.
Observe the patient’s chest wall symmetry during the
Sleep disturbance and snoring may be related to obstruc- respiratory cycle, anatomical structures, and the presence
tive sleep apnoea (OSA). If the patient complains about of scars. The most important sign of respiratory distress
drowsiness in the daytime, ask how many hours of con- is respiratory rate and rhythm. Count the rate for a one-
tinuous sleep they have at night, and whether they take minute period. Normal respiratory rate for adults is
a nap during the day. 12–15 per minute. Abnormal breathing patterns are
4
noted in Table 13.1. Observe respiratory effort, in particu-
Personal and Family History lar the use of accessory muscles, abdominal muscles,
Patient family history and environment can influence nasal flaring, body position and mouth-breathing.
pulmonary presentations. The focus of this questioning Inspect the lips, tongue and sublingual area for central
is on: tobacco use, allergies, recent travel, type of occupa- cyanosis (a late sign of hypoxia that is almost impossible
tion, home situation and family history. Use of tobacco, to detect in a patient with anaemia). Observe the extrem-
1
current or past, is important in evaluating pulmonary ities for oedema (can be a sign of heart failure), fingers
symptoms. Ask the patient to quantify the amount of and toes for peripheral cyanosis and clubbing of the nail-
cigarette packs per week and how many years they have beds. Peripheral cyanosis can appear with low blood flow
smoked. The majority of smokers have reduced lung to peripheral areas. Clubbing of finger or toe nailbeds can
function. Tobacco smoking is responsible for 80–90% of be idiopathic in nature or more commonly due to respi-
the risk of developing chronic obstructive pulmonary ratory and circulatory diseases (e.g. chronic hypoxia in
disease but only 10–15% of these patients will develop congenital heart disease). 14,22
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clinically significant symptoms. Exposure to second-
hand smoke may also be of interest. There is Note also if the patient requires oxygen and observe the
evidence that exposure to secondhand smoke for an dose. If the patient is intubated and mechanically venti-
extended period is a major cause in developing chronic lated (monitoring is explained later in this chapter),
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bronchitis. A history of recent travel increases the pos- ensure the airway is adequately secured. If the patient is
sibility of exposure to infectious diseases affecting the orally intubated, observe the mouth for the presence of
25
respiratory system. Recent long flights are also respon- lesions or pressure on the oral mucosa and lips;
sible for the possibility of deep venous thrombosis which and observe the size of the tube, the length at the lips or
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can lead to pulmonary embolism. An occupation with teeth margin, and how it is secured. If the patient has a