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Cardiac Rehabilitation

Introduction
“Cardiac Rehabilitation is the process by which patients with cardiac
disease, in partnership with a multidisciplinary team of health
professionals are encouraged to support and achieve and maintain optimal
physical and psychosocial health. The involvement of partners, other
family members and carers is also important” [1]

Cardiac rehabilitation is an accepted form of management for people with

cardiac disease. Initially, rehabilitation was offered mainly to people
recovering from a myocardial infraction (MI), but now encompasses a wide
range of cardiac problems. [2]

To achieve the goals of cardiac rehabilitation a multidisciplinary team

approach is required. The multidisciplinary team members include:

 Cardiologist/Physician and co-coordinator to lead cardiac rehabilitation

 Clinical Nurse Specialist
 Physiotherapist
 Clinical nutritionist/Dietitian
 Occupational Therapist
 Pharmacist
 Psychologist
 Smoking cessation counsellor/nurse
 Social worker
 Vocational counsellor
 Clerical Administraton [3]

It is essential that all cardiac rehabilitation staff have appropriate training,

qualifications, skills and competencies to practice within their scope of
practice and recognise and respect the professional skills of all other
disciplines involved in providing comprehensive cardiac rehabilitation.The
cardiac rehabilitation team should actively engage and effectively link with
the general practitioner and practice nurses, sports and leisure industry
where phase IV is conducted, community pharmacists and other relevant
bodies to create a long term approach to CVD management. [4]

Description
[5]

Indication
Cardiac rehabilitation should be offered to all cardiac patients who would
benefit.[2] CR is mainly prescribed to patients with ischemic heart disease,
with myocardial infarction, after coronary angioplasty, after coronaro-
aortic by-pass graft surgery and to patients with chronic heart failure. CR
begins as soon as possible in intensive care units, only if the patient is in
stable medical condition. Intensity of rehabilitation depends on patient´s
condition and complications in acute phase of disease. [6]

Goals of Cardiac Rehabilitation

The main goal of cardiac rehabilitation is to promote secondary prevention
and to enhance quality of life among cardiac patients (WHO, 1993)

Medical Goals Social Goals Psychological Goals Behav

Goals

Improve Cardiac Function Return to work if appropriate To restore self confidence To quit
and/or previous level of smokin
functional capacity
Reduce the risk of sudden To promote independence in Relieve anxiety and To mak
death and re-infarcation ADLs for those who are depression in pt.s and their dietary
compromised careers

Relieve symptoms such as To relieve or manage stress To be p

breathlessness and angina active

Increase Work Capacity To restore good sexual To adh

health medica

Prevent progression of
underlying atherosclerotic
process

[4]

Individual Risk Assessment

CR can be tailored to meet individual needs thus a thorough assessment
and evaluation of the CV risk factor profile of the patient should be
undertaken at the beginning of the programme. This should be
accompanied by ongoing assessment and reassessment throughout and
upon completion of the programme. [4]

Risk factors should be evaluated using validated measures which take into
account other co-morbidities.

RISK FACTORS

Non Modifiable Modifiable

Age Excessive alcohol intake

Gender Dyslipedemia

Personal Cardiac History Hypertension

Family History of CVD Obesity

Diabetes (unless prediabetes) Smoking

 Physical Inactivity

Anxiety/Depression

Hostility

Stress
[1][3][7]

Other factors to consider

 Family Support
 Social History
 Occupation

Cardiac Rehabilitation Participation

Participation in cardiac rehabilitation programs should be available to all
cardiac patients who require it. Age is not and should not be a barrier to
cardiac rehabilitation participation [4]. However, consideration of patient
safety results in the following specific inclusion/exclusion criteria applying
to participation in the Phase III exercise component. [8]

Inclusion Exclusion

Medically stable post MI Unstable Angina

Coronary Artery Bypass Surgery Ischaemic changes on ECG

Percutaneous Coronary Intervention Resting systolic BP >200mm

Stable Angina Orthostatic BP drop >10mmH

Stable heart failure (NYHA I-III) Critical aortic stenosis (peak

valve orifice <0.75cm2
Cardiomyopathy Acute systemic illness or feve

Cardiac Transplantation Uncontrolled atrial or ventric

Implantable Cardioverter Defibrillator Uncontrolled sinus tachycard

Valve Repair/Replacement Uncompensated CHF

Insertion of Cardiac Pacemaker (with one or more other inclusion Acute systemic illness
criteria)

Peripheral Arterial Disease 3rd degree AV block with no p

Post Cerebral Vascular Disease Acute pericarditis/myocarditi

At risk of coronary artery disease with diagnosis of diabetes, Recent embolism

dyslipedemia, hypertension

Thromobophlebitis

Uncontrolled diabetes

Severe orthopediac problems

Other metabolic problems suc

hypovolemia

[4][8]
 Phases of Cardiac Rehabilitation
Cardiac rehabilitation typically comprises of four phases. The term phase is
used to describe the varying time frames following a cardiac event. The
secondary prevention component of CR requires delivery of exercise
training, education and counseling, risk factor intervention and follow up. [9]

Appropriate referral pathways should be set up so appropriate patients can

be identified and invited to attend. Referrals should be invited by
cardiologist/physician, cardiothoracic surgeon, cardiac team, cardic rehab
co-ordinator, G.P., CCU nurses or members of the MDT. All referrals
should include the following;

 Patients name, age, address and contact number

 Type of cardiac event and date of event
 Cardiac history, complications and meds
 Reason for referral
 Referring persons name and contact number, date of request
 Clinically relevant information – results of exercise stress test, echo, fasting
lipid profile and fasting glucose profile [1]

Phases of Cardiac Rehabilitation

Phase I: In hospital patient period

2-5 days

Member of Cardiac Rehab team (CRT) should visit the patient to;

 Give support and information to them and their families re: heart disease
 Assist the patient to identify personal CV risk factors
 Discuss lifestyle modifications of personal risk factors and help provide an
individual plan to support these lifestyle changes
 Gain support from family members to assist the patient in maintaining the
necessary progress
 Plan a personal discharge activity programme and encourage the patient to
adhere to this and commence daily walks
 Inform patients regarding phase II and phase III programs if available and
encourage their attendance

At this stage emphasis is on counteracting the negative effects of a cardiac

event not promoting training adaptations (Woods, 2010). Activity levels
should be progressed using a staged approach which should be based on
the patient’s medical condition. Patient should be closely monitored for
any signs of cardiac decompensation.

Educational sessions should be commenced providing information re:

 The cardiac event

 Psychological reactions to the event
 Cardiac pain/symptom management
 Correction of cardiac misconceptions

The use of educational materials such as the heart manual and leaflets from
the Irish Heart Foundation should be considered.

Patient should be provided with an individual plan for self care and
lifestyle changes based on their clinical assessment and identified risk
factors. A discharge plan including exercise instructions should also be
formulated.

Patient should also have some form of psychosocial assessment either via
interview or use of a self reporting questionnaire such as HADS, Health
Realted QoL.

Referrals to other members of the MDT and follow up visits should also be
made during this time. [4]

Phase II: Post discharge period

Goals:

 Reinforce cardiac risk factor modification

 Provide education and support to patient and family
 Promote continuing adherence to lifestyle recommendations. [10]

SIGN 2002 – state the importance of addressing any psychological distress

or poor social support issues as these two factors have been identified as
being powerful predictors of outcome post MI irrespective of the degree of
physical impairment. [1]

Support and education can be provided through

 Home visits
 Phone calls
 Outpatient reviews

Provision of educational classes (individual/group)

Use of the heart manual

Could also look into establishing links with GP, practice nurses, primary
care team and chest pain services.

Gradual activity and low level exercise regime may commence once stable.
Intensity will increase over a varying period of time depending on
diagnosis and procedure and is done under guidance of the cardiologist

ACSM suggest 4-6 weeks post MI and post sternotomy unless otherwise
directed by cardiologist/cardiothoracic surgeon [11][12]

Phase III: Cardiac Rehabilitation and secondary

prevention
Structured exercise training with continual educational and psychological
support and advice on risk factors [1]

Should take a menu based approach and be individually tailored.

Typically lasts at least 6 weeks with patients exercising 2/7 minimum.

Exercise class will consist of warm up, exercise class, cool down – may also
include resistance training with active recovery stations where
appropriate.[8]
 Phase III compromises of all the following;

 Exercise prescription based on

 Clinical status
 Risk Stratification
 Previous activity
 Future needs[11]

 Education for patient and family re:

o Cardiac anatomy and physiology

o Recognition of cardiac pain and symptom management

o Risk factor identification and management

o Benefits of PA

o Energy conservation techniques/graded return to ADLs

o Cardio protective healthy eating

o Benefits and entitlements

 Stress management and relaxation techniques

 Counselling and behaviour modification
 Smoking cessation
 Vocational counselling [4]

Sample format of a Cardiac Rehabilitation Class

- Check in (vitals assessed)

- Warm Up (15 mins)

- Main class (30 mins)

- Cool down (10 mins)

- Monitoring and reassessment of vitals and check out

 Warm Up

Purpose: Prepare the body for exercise by raising the pulse rate in a
graduated and safe way

Effects:

 redistributes blood to active tissues

 increases muscle temperature and speed of muscle action and relaxation
 prepares the mind
 prepares the muscle for the ROM involved for the conditioning period

Should include pulse raising activities (5 minutes) eg) marching on the

spot, walking, low level cycle followed by stretching of the major muscle
groups (5 mins) followed by more pulse raising activity.

NB: should try to keep feet moving at all times to maintain HR and body
temp and avoid pooling.

Main Class:

For group rehab circuit training seems most popular. Depending on CV

status and functional capacity patients may adopt an interval or continuous
approach to the circuit.

Separate stations are set out and participants spend a fixed amount of time
at each aerobic station (30secs-2mins) before moving onto the next station
which may be rest or active recovery in the form of resistance work
targeted at specific muscle groups.

Resistance work as set out by ACSM 2006 – 10-15 reps to moderate fatigue
of 8-10 exercises.[13][14]

Individualisation of the CV component can be achieved by varying;

duration spent at each CV station, intensity (increase resistance, speed or
ROM), period of rest, overall duration of the class [11]

Cool Down:

10 minutes at the end

Goal: bring the body back to its resting state

 Should incorporate movements of diminishing intensity and passive
stretching of the major muscle groups.

Necessary because of;

 Increased risk of hypotension

 Older hearts take longer to return to resting levels
 Raised sympathetic activity during exercise increases the risk of arrhythmias
immediately post exercise. [11]

Phase IV: Maintenance

Goal: facilitate long term maintenance of lifestyle changes, monitoring risk

factor changes and secondary prevention. [10]

Options:

 Educational sessions
 Support groups
 Telephone follow up
 Review in clinics
 Outreach programmes
 Phase IV exercise programme organised by qualified phase IV gym
instructor
 Links with GP and primary health care team
 Ongoing involvement of partners/spouses/family [4]

Health and Safety

Patient shouldn’t exercise if they are generally unwell, symptomatic or
clinically unstable on arrival;

 Fever/acute systemic illness

 Unresolved/unstable angina
 Resting BP systolic >200mmHg and diastolic > 110mmHg
 Significant drop in BP
 Symptomatic hypotension
 Resting/uncontrolled tachycardia (>100bpm)
 Uncontrolled atrial or ventricular arrhythmias
 New/recurrent symptoms of breathlessness, lethargy, palpitations, dizziness
 Unstable heart failure
 Unstable/uncontrolled diabetes [15][4]
 Need to consider the following;

 Local written policy clearly displayed for the management of emergency

situations
 Rapid access to emergency team in hospital or via ambulance
 Regular checking and maintenance of all equipment
 Drinking water and glucose supplements available as required
 Access to and from venue, emergency exits, toilets and changing areas,
lighting, surface and room space checked to ensure they’re appropriate
 Enough space for patient traffic and safe placement of equipment
 Adequate temperature and ventilation
 Medications of patients and their associated effects

Assessment and Outcome Measures

It is essential to;

 set and evaluate the effectiveness of an exercise programme

 provide objective feedback to the patient
 facilitate evidence based practice

Measures can be used as both a baseline measure and exit outcome

measure. These may include;

 HR and BP @ rest and during exercise

 RPE
 Body weight
 BMI
 Waist circumference

Measures of functional capacity;

 6MWT
 shuttle walk test
 chester step test
 A patient having a stress test. Electrodes are attached to the patient's chest and connected to an EKG
machine. The EKG records the heart's electrical activity. A blood pressure cuff is used to record the
patient's blood pressure while he walks on a treadmill. [16]

Exercise Testing and Risk Stratification

EACPR, ACCPVR, CACR, ESC and AHA all recommend exercise testing as
part of a patient’s initial assessment for cardiac rehabilitation. Exercise
testing allows for the following;

 Diagnosis – identification of patients with CHD and the severity of the

disease
 Prognosis – identification of low, moderate and high risk patients
 Evaluation – establishment of the effectiveness of a selected intervention
 Measurement of functional capacity – used as a basis for advice re ADLs and
development of a formal exercise prescription
 Measurement of acute exercise responses – BP, HR, ventilator responses
and detection of exercise induced arrhythmias
 To provide an appropriate training target HR [14]

Exercise ECG using an incremental protocol is most commonly used and

before acceptance into the phase III programme a symptom limited test is
customary. Usually uses the Bruce Protocol

Criteria for terminating a test;

Horizontal or downsloping ST segment depression >2mm – indicates ischaemia

Marked drop in systolic BP >20mmHG – indicates poor LV fxn or severe coronary disease
Serious arrhythmias – ventricular tachycardia

Patient fatigue and/or excessive breathlessness at low workloads – poor fxnl capacity or more serious

[14]

Negative Test Positive Te

Normal haemodynamic response Significant EC

Completion of a workload equivalent to the second stage of the Bruce protocol (7 Inappropriate
METs) workload.

NB: when carrying out the test patients HR, BP and 12 lead ECG must be
constantly assessed. Once test has terminated recovery monitoring must be
continues for a minimum of 6 secs or until the ECG returns to its pretest
appearance.[14]

Risk Stratification

Definition: “Evaluation of the patient to assess the degree of risk of

future cardiac events associated with exercise”[1]

Low Risk (all characteristics listed Moderate Risk (any one or a High R
must be present to remain @ lowest combination of these findings)
risk)

Uncomplicated MI, CABG, angioplasty Functional capacity <5-6 METs Severel

Funct. Capacity >6 METs Mild – moderate depressed LV Comple

dysfunction (EF 31-49%)

No resting/exercise induced complex Mild – moderate ischaemia in Decreas

 arrhythmias exercise/recovery exercise
exercise

No sig. LV dysfunction (EF >50%) Exercise induced STsegment depression MI com

of 1-2mm or reversible ischaemic effects shock/c

Normal heamodynamic response during Presence of angina or relevant Severe

exercise symptoms at high levels of exertion (>7 ST sege
METs)

Absence of CHF Survivo

Absence of angina/other sig symptoms Compli

Absence of clinical depression Presenc

[8]

Risk stratification is important as it will have a bearing on staffing required

and group mixing. It’s also something that has to be taken into account
when determining the level of monitoring a patient requires and when
setting their Target Training HR.

Requirements for cardiac Rehabilitation

Facilities and Equipment

The minimum facilities necessary to provide a cardiac rehabilitation

service are:

 Separate office space and facilities for cardiac rehabilitation staff

 An Education Room furnished with seats, TV and DVD player and with a
selection of information booklets and DVD’s provided. The size of the
education room will depend upon the number of participants (patients,
spouses, and staff) in the education sessions and given resources.
 It is recommended that the exercise warm-up area and the exercise room
combined should be approximately 300m2
 The exercise room should be air-conditioned
 In addition, patients should have access to
 Toilet
 Shower and changing room
 Available drinking water [4]

Equipment in the exercise room may include

Central monitor and telemetry Treadmill Versa climber

Equipped emergency trolley, portable suction, Dual cycle Hand crank

defibrillator and oxygen ergometer

Automated Blood Pressure Recording Machine e.g. Bicycle Multigym weights system
Dinamap ergometer dumb bells

[4]

Staffing Levels

ACPICR 2009 – minimum staff to patient ratio should be 1:5 but this will
vary depending on the risk stratification profile of the class. For higher risk
patients will have increased staff ratio eg) 1:3

SIGN 2002 guidelines: Staff should have basic life support training and
the ability to use a defribillator required for low-moderate risk patients [1]

Resources
 Irish Heart Foundation
 BACPR
 European Society of Cardiology
 SIGN Guidelines

References
1. ↑ Jump up to:1.0 1.1 1.2 1.3 1.4 1.5 1.6 Scottish Intercollegiate Guidelines Network
(SIGN) Cardiac rehabilitation: a national clinical guideline, 2002
2. ↑ Jump up to:2.0 2.1 Pryor JA, Prasad SA. Physiotherapy for Respiratory and Cardiac
Problems. Philadelphia: Elsevier Ltd, 4th Edition, 2008: 14 (470 - 494).
3. ↑ Jump up to:3.0 3.1 American Association of Cardiovascular and Pulmonary
Rehabilitation Robertson, L (Ed.) (2006) Cardiac Rehabilitation Resource
Manual. Champaign: Human Kinetics.
4. ↑ Jump up to:4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Irish Association of Cardiac
Rehabilitation Guidelines 2013
5. Jump up↑ Cardiac Rehabilitation Program. Available
from: http://www.youtube.com/watch?v=famkb_dtAF0 (accessed 20 Oct
2013).
6. Jump up↑ Cardiac rehabilitation. Available
from: http://www.pnmedycznych.pl/spnm.php?ktory=369 (accessed
22.12.2013)
7. Jump up↑ British Association of Cardiac Rehabilitation. “Risk Factors” in
Brodie, D. ed. (2006) Cardiac Rehabilitation: An Educational resource.
Buckinghamshire: Colourways Ltd.
8. ↑ Jump up to:8.0 8.1 8.2 8.3 American Association of Cardiovascular and Pulmonary
Rehabiliation: Guidelines for Cardiac Rehabilitation and secondary
prevention programs 2004
9. Jump up↑ American Association of Cardiovascular and Pulmonary
Rehabilitation Williams, M.A. (Ed.) (2004) Guidelines for Cardiac
Rehabilitation and secondary Prevention programs. Champaign: Human
Kinetics.
10. ↑ Jump up to:10.0 10.1 British Association for Cardiovascular Prevention and
Rehabilitation. (2012) The BACPR standards and core components for
cardiovascular disease prevention and rehabilitation 2012. 2nd Edition.
London: British Cardiovascular Society.
11. ↑ Jump up to:11.0 11.1 11.2 11.3 Association of Chartered Physiotherapists in Cardiac
rehabilitation (2009) Standards for Physical Activity & Exercise in the
Cardiac Population.
12. Jump up↑ American College of Sports Medicine. ACSM's Guidelines for
Exercise Testing and Prescription. Philadelphia :Lippincott Williams &
Wilkins, 2000
13. Jump up↑ Bjarnason-Wehrens, B. Mayer-Berger, W. Meister, E.R. Baum, K.
Hambrecht, R. And Gilen, S. (2004) ‘Recommendations for resistance
exercise in cardiac rehabilitation. Recommendations of the German
Federation for Cardiovascular Prevention and Rehabiliation’. European
Journal of Cardiovascular Prevention and Rehabilitation, 11(4):352-61.
14. ↑ Jump up to:14.0 14.1 14.2 14.3 American College of Sports Medicine (2006) Guidelines
for Exercise Testing and Prescription. 7th Edition. Baltimore, Maryland:
Lippincott Williams & Wilkins.
15. Jump up↑ American Diabetes Association (2013) ‘Standards of Medical Care
in Diabetes—2013’, Diabetes Care, 36: S11-S66.
16. Jump up↑ https://www.nhlbi.nih.gov/health/health-
topics/topics/stress/during
https://www.crnbc.ca/Standards/CertifiedPractice/Documents/RemotePractice/780AdultCardioRes
pAssessDST.pdf

https://physiotherapyguide.blogspot.com/2010/06/general-cardio-respiratory-assessment.html

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