CAE B: Assessment

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Author:
samatwell
ID:
93508
Filename:
CAE B: Assessment
Updated:
2011-07-09 23:34:18
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Asthma
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Description:
Asthma Educator
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  1. 4 symptoms of asthma
    • 1. Dyspnea
    • 2. Chest tightness
    • 3. Coughing (may be only symptom, esp in kids)
    • 4. Wheezing
  2. Additional s/s of asthma
    • 1. Irritability, quietness or fatigue
    • 2. Runny / stuffy nose ***
    • 3. Chest pain / heart palpatations
    • 4. Dark circles under eyes / watery eyes
    • 5. Scratchy throat
    • 6. Flare up of eczema ***
    • 7. Heartburn
    • 8. Children c/o upset stomach
  3. Steps in diagnosing asthma
    • 1. Complete medical hx
    • 2. Physical exam
    • 3. PFT
    • 4. Additional test to exclude other possibilities
  4. Interview - LOC
    • Alert / responsive
    • Lethargic
    • Stuporous
    • Semicomatose (only respond to pain)
    • Coma (no response to pain)
    • Obtunded - drowsy state, dec cough or gag
  5. 6 ADL criteria
    • 1. Bathing with sponge, bath or shower
    • 2. Dressing
    • 3. Toilet use
    • 4. Transferring to bed or chair
    • 5. Urine / bowel continence
    • 6. Eating
  6. Subjective symptoms
    • Orthopnea
    • General malaise
    • Dyspnea
    • Pain
    • Nose / throat symptoms
  7. Orthopnea
    • Dyspnea except in upright position
    • (heart problems, CHF)
  8. General malaise
    Electrolyte imbalance
  9. Dyspnea grades
    • Grade 1 - normal dyspnea after unusual exertion
    • Grade 2 - dyspnea after hills or stairs
    • Grade 3 - dyspnea after normal speed walk
    • Grade 4 - dyspnea after short slow walk
    • Grade 5 - dyspnea at rest
  10. 8 Pain questions
    • 1. Location
    • 2. Quality
    • 3. Severity (on 10 pt scale)
    • 4. Aggrivating factors
    • 5. Relieving factors
    • 6. Hx
    • 7. Context
    • 8. Accompanying symptoms
  11. Nose and throat symptoms
    • 1. Excessive nasal secretions from irritants, pollution, allergens
    • 2. Itching or burning of nose / throat
    • 3. Dysphagia / hoarseness
  12. Adult normal vital signs
    • HR: 60-100
    • RR: 12-20
    • BP: 120/80
    • Temp: 37C or 98.6F
  13. Children normal vital signs
    • HR: 80-120
    • RR: 20-30
    • BP: 100/65
    • Temp: 37C or 98.6F
  14. Physical exam for 7 items
    • 1. Hyperexpanded chest
    • 2. Hunched shoulders
    • 3. Accessory muscle use
    • 4. Chest deformity
    • 5. Prolonged exhalation
    • 6. Nasal mucosal swelling, secretions, nasal polyps, sinusitis, rhinitis
    • 7. Skin conditions (atopic dermatitis or eczema)
  15. Types of tactile fremitus
    Vocal fremitus - voice vibrations

    Pleural rub fremitus - grating sensation du to roughened pleural surfaces

    Rhonchial fremitus (palpable rhonchi) - secretions in the airways
  16. 5 Percussion sounds
    • Resonance - normal air filled lungs (hollow)
    • Flatness - sternum, muscles, atelectasis
    • Dullness - fluid filled organs, pleural effusion, pneumonia (drum sound)
    • Tympany - air filled stomach, hyperinflation
    • Hyperresonance - asthhma, emphysema, pneumothorax (booming sound)
  17. Normal diaphragmatic excursion
    3 to 5 cm
  18. Vesicular normal breath sounds
    • Silent
    • Bronchial breath sound - normal over trachea or bronchi
    • If over lung periphery, lung consolidation
  19. Unilateral wheeze
    • Not asthma
    • Foreign body obstruction
  20. Abnormal breath sounds
    • Wheeze
    • Silent chest
    • Rales and ronchi - secretions
    • Stridor - Inspiration, swelling or foreign body obstruction
  21. Xray with asthma
    • Increased bronchial wall markings (inflammation)
    • Flattened diaphragm
    • Patchy infiltrates from atelectasis
  22. ABG with mild to moderate asthmatic episode
    Uncompensated respiratory alkalosis with hypoxemia

    Needs oxygen therapy
  23. ABG with severe asthmatic episode
    Uncompensated respiratory acidosis with hypoxemia

    Needs mechanical ventilation and oxygen therapy
  24. RBC normal values
    • Male: 4.7 to 6.1 million cells / mcl
    • Femal: 4.2 to 5.4
  25. Hemoglobin normal values
    • Male: 13.8 to 17.2 gm/dl
    • Female: 12.1 to 15.1
  26. Hematocrit normal values
    • Male: 40.7 to 50.3%
    • Female: 36.1 to 44.3%
  27. WBC normal values
    • 4500 to 10000 cells/mcl
    • elevated indicates bacterial infection
    • reduced indicates viral infection
  28. Eosinophil normal values
    • < 350 cells/mcl
    • elevated indicates allergic diseases or asthma
  29. Immunoglobulins
    antibodies produced by the immune system in response to bacteria, viruses or foreign bodies

    if IgE levels are high, allergy testing!
  30. Screen for immunodeficiency
    To determine if diseases are present to make it difficult for the body to fight infections
  31. Sweat chloride testing for children with chronic asthma
    • r/o cystic fibrosis
    • diagnosis of asthma in children < 3 is difficult
  32. Age to test PFT for diagnosis of asthma
    5
  33. Define diurnal variability
    variability (improvement or deterioration) experienced in PFTs within one day
  34. How often should PFTs be performed
    • When asthma is under control
    • Then every 1 to 2 years
  35. Is asthma obtructive or restrictive?
    • Both
    • Primarily obstructive that can cross over to restrictive
    • Goal: manage before it becomes restrictive
  36. Normal FVC and FEV1
    • FVC: 4.8 L
    • FEV1: 70% of FVC (minimum)
  37. Normal PF
    • 10 L/sec or 600 L/min
    • Best way to monitor pt with asthma and measure MDI
    • 60 L/m or >=20% in PF is dianostic of asthma
    • Should measure daily
  38. Classification of interpretation of % predicted
    • 80-100% Normal
    • 60-79% Mild
    • 40-59% Moderate
    • <40% Severe
  39. PFT reversibility values
    • FEV1: 12% and 200ml
    • or 12% in FVC
  40. Medication hold times for pre-post testing
    • SABA: 4-6 hours
    • LABA: 12 hours
    • Methylxanthines: 12 hours
    • Slow release methylxanthines: 24 hours
    • Ipratropium bromide: 6-8 hours
  41. Percent change formula
    (Post FEV1 - Pre FEV1) / (Pre FEV1) X 100
  42. Bronchoprovocation tests
    • Methacholine
    • Histamine
    • Cold air
    • Exercise
  43. Medication hold times for bronchoprovocation test
    • Bronchodilators: 8 hours
    • Methylxanthines: 12 hours
    • Cromolyn Sodium: 24 hours
    • Antihistamines: 48 hours
  44. DLCO in asthma
    • helps differentiate between asthma and emphysema
    • Normal is 25 ml CO/min/mmHg (STPD)
    • Normal in asthma
  45. Allergic reaction process
    • Antigen or allergen inhaled or ingested
    • Immune system detects and releases IgE antibodies
    • IgE attach to mast cells and basophils to act as guards
    • When allergen/antigen contacts mast cell, IgE shoots hole into the mast cell
    • Mast cell releases histamine, leukotrienes and chemicals resulting in allergic reaction
  46. Medication hold times for allergy test
    Antihistamines: 2 days
  47. Allergy test types
    Skin-prick: red bumps within 20 minutes

    • Intracutaneous test: only if skin prick inconclusive
    • monitor patient for systemic reaction
  48. Blood allergy test
    • Use if not advisable to dc antihistamines
    • Radioallergensorbent testing (RAST)
    • Enzyme-lined immunosorbent assay test (ELISA)
    • Less accurate, more expensive, slower
    • Thus, less used
  49. Immunotherapy (allergy shots or desensitization)
    • Decreases IgE
    • Increasing doses of allergen extract 1-2 per week
    • Maintenance dose in 3 to 6 months (symptom relief)
    • Then, once a week, reducing to every 4 weeks
    • Wait 20 minutes
    • Program lasts 3 to 5 years
  50. Non-Invasive Markers (Biomarkers)
    • Sputum and blood for eosinophilic cationic protein ECP
    • FeNO
    • Metabolites in exhaled breath condensate EBC
    • Needs further studies before approved to monitor
    • not usually asked
  51. Infant and children other possible diagnosis
    • 1. Allergic rhinits (hay fever) or sinusitis ***
    • 2. Swallowing problems
    • 3. Congenital heart disease
    • 4. Obstruction of the large or small airways
    • 5. Tumors or enlarged lymph nodes
    • 6. Cystic fibrosis ***
  52. Adult other possible diagnosis
    • 1. COPD ***
    • 2. Pulmonary embolism
    • 3. Heart disease
    • 4. VCD ***
    • 5. Airway tumors
    • 6. Coughing due to drug reaction
    • 7. Pregnancy
    • 8. GERD ***

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