LOG #2 Signs and Symptoms Patient Assessment LOG #2 Signs and Symptoms

Cough Most common symptom in patients with pulmonary disease Purpose Aids in removal of materials from the respiratory tract by providing high-velocity airflow on expiration Protective mechanism

Cough Irritants 1. Secretions Post-nasal drip Secretions from the lung inflammatory response 2. Inspired irritants Cigarette smoke, chemicals, food, cold air, fumes 3. Tumour 4. Airway hyperactivity Asthma, (some COPD) Secretions = infections (inflammation) e.g. pneumonia, bronchitis, left heart failure, post nasal drip. Inspired Irritants = cigarette smoke, cold air, chemicals/gasses. Tumour = lung, throat. Airway hyperactivity = asthma.

Types of Cough 1. Upper airway problems Barking, hoarse 2. Bronchial Wheezy, whistling 3. Broncho-pulmonary disease Chronic 4. Smoking, viral, nervous, and PND Upper airway = barking, hoarse bronchial = wheezy (whistling) Broncho-pulmonary disease = chronic, productive Smoking, viral, nervous, and PND = hacking (frequent periods of coughing or clearing throat)

Cough Reflex A reflex that arises from stimulation of cough or irritant receptors Receptors located in Pharynx Larynx Trachea Large bronchi Visceral pleura

Cough Reflex cont. When stimulated Receptors send a signal via glossopharyngeal (IX) and Vagus (X) nerves to the cough reflex centre in the medulla (centre in the brain) The medulla then causes the glottis to close and accessory muscles of expiration to contract

Cough Mechanism 1. Stimulation 2. Deep breath – 3. Inspiratory pause – 2. Deep Breath = effectiveness of cough guideline = a) insp. capacity greater than 75% b) vital capacity greater than 15 mls. /kg 3. Inspiratory Pause = aids gas distribution and therefore mucus mobilization 4. Glottic closure 5. Compression phase = contraction of expiratory muscles increased intrathoracic pressure trapped air in lungs is compressed 6. Glottic opening = blast of air rushes upward at high velocity, therefore transports mucus.

Cough Mechanism cont. 4. Glottic closure (Compression phase) – 5. Glottic opening –

Coughing cont. Valsalva manoeuvre Increased intrathoracic pressure by forcible exhalation against a closed glottis. Efficiency of cough determined by Depth of inspiration Amount of pressure generated. Depends on – The cough mechanism = Valsalva manoeuvre

Hazards of Coughing 1. Cough syncope – 2. Pneumothorax 3. Hemoptysis 4. Spread of infection 5. Rib fracture Others not as common Torn chest muscles Urinary incontinence Esophageal rupture Cough syncope (vaso vagal) = increased intrapulmonary pressure = decreased venous return = decreased cardiac output = cerebral ischemia Pneumothorax = rib fracture Aka vasovagal syncope = loss of consciousness due to increased vagus nerve activity (paraympathetic)

Productive vs. Non-Productive Secretions Blood Non-Productive Irritation (non-expectorating) May be due to inflammation, growth, reflex Effective Cough – Strong enough to clear secretions Ineffective Cough – Inefficient or unable to clear secretions

Expectoration Sputum comprised of Mucus Sol layer – Gel layer – Others WBC Blood Aspirate Dead tissue cells Pharyngeal Sputum – Phlem – Gel layer = top, gelatanous Sol layer= liquid colloid

Important Aspects of Sputum Expectoration 1. Colour Clear – Yellow – White/yellow – Green – Red – Brown – Pink/frothy – Black/grey – Clear = normal white/mucoid = asthma yellow = WBC (Pus)= infectlion Green= stagnant pus, old infection Yellow and Green copious = purulent Creamy and stringy = mucopurulent, infectopmj, cf, pneumonias red = blood brown, rusty= old blood, certain pneumonias pink frothy = pulmonary edema Black = smoke or coal dust foul smelling = abscess, bronchiectasis, anaerobic infections, aspiration Bronchiectasis = separates into layers

Expectoration cont. 2. Consistency 3. Volume Watery Thick Sticky Solid 24-hour period How much?

Expectoration cont. 4. Odour 5. When Foul (Anaerobic) A.M / P.M? Irritants

Potential Hazards of Retained Secretions 1. Inflammation Increased Raw (Airway resistance) Increased WOB 2. Partial airway plugging Uneven distribution of ventilation Shunt effect (perfusion in excess of ventilation) Hypoxemia

Hazards cont. No ventilation Atelectasis 3. Total airway plugging No ventilation Atelectasis Decreased Cl, therefore increased WOB Shunting, therefore hypoxemia

Hemoptysis Definition Etiology Expectoration of fresh blood Massive hemoptysis = greater than 600 mls. /24 hrs. Etiology 1. Neoplasm – 2. Infection – 3. Cardiovascular – 4. Pulmonary embolism – Neoplasm = Bronchogenic carcinoma, pulmonary lesion Infection = TB, absess, pneumonia, Bronchiectasis, CF Cardiovascular = pulmonary embolism, CHF, Mitral stenosis

Patient Assessment Signs and Symptoms Dyspnea

Dyspnea Patient awareness of difficulty in breathing or S.O.B. in an inappropriate setting At rest Activities of daily living Sleeping Speaking Bathing

Causes Upper airway obstruction Asthma C.O.P.D Pulmonary fibrosis 1.Altered lung mechanics Increased Raw Upper airway obstruction Asthma C.O.P.D Decreased compliance Pulmonary fibrosis Congestion Edema Atelectasis

Dyspnea Causes cont. Hypoxemia Hypercapnea Acidemia 2. Increased ventilation Hypoxemia Hypercapnea Acidemia Cardiac dysfunction

Dyspnea Causes cont. Weakness Paralysis Atrophy 3. Respiratory muscle abnormalities Weakness Paralysis Atrophy

Dyspnea Causes cont. Pneumothorax Pleural effusion 4. Mechanical interference to expansion of lungs Pneumothorax Pleural effusion 5. Psychogenic

Dyspnea Variations Heart failure Advanced pulmonary disease Orthopnea Dyspnea while lying down Heart failure Advanced pulmonary disease Paroxysmal nocturnal dyspnea Sudden onset of S.O.B at night (in a sleeping pt.) Cardiac patients

Exertional dyspnea Dyspnea developed upon exertion in a normal situation

Patient assessment Signs and Symptoms Cyanosis

Definition Bluish discolouration of skin and mucous membranes

Due To An excess of deoxygenated hemoglobin in the blood Usually greater than 50 gm/L of unsaturated Hb (Normal = 120-160 gm/L)

Central vs. Peripheral Under tongue Conjunctiva of the eye Lips Central – (Pt trunk and oral mucosa) High vascular areas Under tongue Conjunctiva of the eye Lips

Central cont. Decreased PaO2 (less than 50 mmHg) Decreased pulmonary or cardiac Fx Good indicator of hypoxemia

Peripheral Fingertips Toes Normal PaO2 (Mostly) Decreased peripheral circulation Cold (Vasoconstriction) Perfusion (Decreased cardiac output)

To Differentiate Central and Peripheral ABGs Check sublingual cyanosis

So Clinically… Cyanosis = PaO2 less than 50 mmHg SaO2 less than 80% *LATE SIGN OF HYPOXEMIA*

Note Polycythemic pt. may have cyanosis with only mild hypoxemia Conversely Anemic pt. may be severely hypoxemic and not cyanotic

Patient assessment Signs and Symptoms Chest Pain

Chest Pain Pain primarily due to Pulmonary Cardiac Mediastinal conditions

1. Pulmonary Chest wall Parietal pleura Localized Constant aching Any movement E.g. rib # Parietal pleura Inspiratory pain Sharp and severe Localized E.g. pleurisy

2. Cardiac Major symptom of cardiac disease Pain is usually diffuse, dull, and radiating E.g. angina or infarction

3. Mediastinal Burning substernal pain May radiate Often assumed to be cardiac E.g. esophagitis

Assessing Chest Pain MIDTERM #1 up to here!! Onset Location Radiation Frequency Duration MIDTERM #1 up to here!! Severity precipitation Relieving factors Description