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Cardiorespiratory Physiotherapy Assessment.

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by

Pang Carmen

on 5 April 2015

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Transcript of Cardiorespiratory Physiotherapy Assessment.

Cardiorespiratory Physiotherapy Assessment.
Subjective Assessment.
Presenting complain:
Patient complain of continuous cough but no sputum.

Present history:
Patient complain of shortness of breath together with dry cough for 3 days prior to being admitted. Firstly, patient went to the clinic because of having difficulty in breathing. After that, the patient was transferred by an ambulance from the clinic to the emergency department at Hospital Temerloh on 22/11/2014. After the investigation, he was diagnosed of having Acute Exacerbation of chronic obstructive airway disease secondary to Hospital Acquired Pneumonia. He was then admitted at K11 ward and was referred to physiotherapy.
Past history:
Patient complain of having recurrent attacks of asthma and admitted at Hospital Temerloh 3 times in 2014. He was admitted for history of asthma attack.

Past medical history:
Asthma under medication
Hypertension under medication (7 years ago)

Drug history:
Broncho dilator
Social history:
Patient is staying with his son. There are no pets in the house. Patient is not a smoker and not an alcoholic
.

Investigate:
Chest X-Ray taken on 22/11/2014: Hyper inflated

Objective Assessment.
Analysis.
Case study.
Name
: Mr. G
Age
: 73 years 2 month
R/N
: 4109090XXXXX
Date of admitted
: 22/11/2014
Date of assessment
: 24/11/2014

Doctor’s diagnosis
: Acute exacerbation of chronic obstructive airway disease secondary to hospital acquired pneumonia.
Doctor’s management
:
Conservative
Medication- Broncho dilator
Chest physiotherapy

Acute exacerbation of chronic obstructive airway disease secondary to hospital acquired pneumonia.

Definition:
Chronic obstructive airways disease is an obstructive lung disease is obstruction to the airflow in the respiratory tract which affect ventilation and gas exchange. Airways disease include asthma, emphysema, bronchiectasis and chronic bronchitis.

Hospital Acquired Disease is infection that acquired in hospitals and other healthcare facilities.










Vital sign:
Blood pressure: 182/92mmhg
Respiratory rate: 21 breaths/min
Heart rate: 96 beats/min
Oxygen saturation: 95% on room air
Temperature: 37 Celsius

Interpretation:
High blood pressure/hypertension.


Observation.

General:
Medium sized Chinese elderly man, was lying in a supine position on the bed. The patient was alert and cooperative. The patients grandson was present during the physiotherapy assessment time.

Local:
Oxygen therapy: No
Chest deformity: Funnel chest
Breathing pattern: Rapid breathing
Breathing level: Apical breathing
Coughing: Effective and non-productive
Sputum: Nil

Palpation.

Chest expansion:

Level Findings
Sternoclavicular notch Symmetrical (Good)
Manubriosternal junction Symmetrical (Moderate)
Xiphoid Symmetrical (Moderate)



Interpretation
: Moderate symmetrical chest expansion at xiphoid and manubriosternal junction.
Percussion note.

Level Right Left
Upper lobe Dull Dull
Middle lobe Resonant -
Lower lobe Resonant Resonant


Interpretation
: Secretion retention at both upper lobes of lungs.


Problem list & Short term goals.
Shortness of breath due to narrowing of airway.

Reduce shortness of breath within 2/7.

Secretion retention at upper lobes of lung due to pathological changes.

Reduce secretion retention within 2/7.

Apical breathing level due to incorrect breathing technique.

Improve breathing level within 2/7.

Reduce chest expansion due to reduce thoracic mobility.

Improve chest expansion within 2/7.

Long term goal.
To regain optimal function capacity with 1/52.

Treatment.
Chest physiotherapy.
Home program.
Patient education and advice.
Thoracic mobility exercise: Breath in through nose, breath out through mouth slowly with raise up the hand: 5-10 repetition.
Active cycle breathing technique exercise: Breathing control x3, thoracic expansion exercise x2, force expiration technique x2 with vibration.
Patient education:
Pursed lip breathing exercise in relaxing position at home.









Intervention.
Thank you.
Auscultation.







Crackle sounds

Interpretation:
Secretion retention in both upper lobes of lung. Good air entry in all level of lung.

Patient cooperative.
Patient’s breathing pattern improve.
Patient able to cough out sputum: Color: Whitish Amount: Small Consistency: Thick

Evaluation.
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