1/25/09

1

  As an RT, you will encounter patients with a variety of symptoms

  In this section we will define terms assoc. with these symptoms, discuss causes, describe normal & abnormal characteristics, & list related symptoms and diseases for each of the primary symptoms

Cough

1/25/09

2

Cough

  1 of the most common symptoms in patients with CP disease

  = powerful airway protective reflexes

  Produced by stimulation of those receptors   Inflammatory   Mechanical   Chemical   Thermal

  May be voluntary or involuntary

Cough

  Efficiency is determined by depth of inspiration and amount of pressure generated during expulsion

  Messed up by   Weakness   Glottic malfunction   Obstruction of airways   Decrease of lung recoil   Overwhelming mucus production

  Can be acute, chronic, paroxysmal

Cough

  Cough may be symptom &/or cause problems itself

1/25/09

3

Cough

  Described as   Effective, strong vs. inadequate, weak   Productive or dry   Barking, brassy, hoarse, wheezy, hacking

  Be careful to note changes

Sputum Production

Sputum Production

  Substance expelled from TB tree, pharynx, mouth, sinuses, nose = ?

  Secretions from TB tree = ?

  Made of mucus, cellular debris, microorganisms, blood, pus, foreign particles

  Normal production = ≤100 ml/day

  Moved up by wave-like motion of cilia

1/25/09

4

Sputum Production

  Note and chart   Amount   Color   Consistency   Odor   Time of day   Presence of blood or other matter

Sputum Production - Amount

  Described as scant - to – copious

Sputum Production - Color

  Clear, colorless

  Black

  Frothy

  Mucoid, gray

  Purulent

  Pink, blood-tinged

  Rusty

  Yellow

  Green

1/25/09

5

Sputum Production - Consistency

  Thin

  Thick, tenacious

  Viscous

  Tenacious

  Frothy

Sputum Production - Odor

  Foul-smelling, fetid

  Note time

Sputum Production - Hemoptysis

  = bloody sputum

  Streaky - to - frank bleeding

  ALARMING!!

  Important to determine where blood is coming from

  Report to RN/physician

1/25/09

6

Dyspnea

Shortness of Breath (SOB)

  = dyspnea   “dys” -   “pnea” -

  Normally you should not be aware of your breathing

  Indicates resp or cardiac disease

  Interferes with work, exercise, ADL

  Frequently is the reason patient goes to Dr.

  Can be slight to severe distress

Dyspnea

  Difficult to assess because is a “symptom”   Sign = objective, numbers, observations   Symptom = subjective, something the patient tells you

  “short of breath”   “difficult to breathe”   “can’t catch my breath”   “short-winded”

1/25/09

7

Dyspnea

  Degree depends on severity of illness & psychological makeup of patient

  Patient’s perception may have no relation to breathing appearance:   Rapid, labored appearance → patient denies SOB   Normal appearance → patient feels SOB

  Perceptions vary:   Healthy person climbs stairs, RR increases -- not

unpleasant   Athlete breathless after a sprint -- feels exhilarated

Dyspnea

  Always take complaints of dyspnea seriously!

Dyspnea

  Dyspnea is rated on a scale

  Rated when?

  Other questionnaires have been developed to rate dyspnea during ADL

1/25/09

8

Dyspnea

  Sometimes description of SOB may help define problem   “tightness”   “suffocation”, “air hungry”   “increased effort to breathe”

Dyspnea

  Generally accepted types of dyspnea:   Pulmonary

  Restrictive   Obstructive

  Cardiac   Circulatory   Chemical   Central   Psychogenic

  PFT, ECG, chest x-ray helpful to differentiate

Dyspnea

  Can be acute   Asthma, diseases, PTE, obstruction, aspiration,

pneumothorax, pulmonary edema, panic disorder

  Chronic   Almost always progressive

1/25/09

9

Shortness of Breath

  Orthopnea

  Treopnea

  Platypnea

  Apnea

  Eupnea

  Hyperventilation

  Hypoventilation

Chest Pain

Chest Pain

  Common symptom in patients with cardiac ischemia   Blocked coronary artery   Must reestablish blood flow quickly

  Can be “referred”

1/25/09

10

Chest Pain

  Cardiac chest pain usually located in center of chest or back, may radiate up in neck, jaw or down arm   “vise-like”   “knife-like” vague uneasiness   “elephant on chest”

  Increases with exercise, diminishes with rest

  If cardiac = angina

  Investigate all chest pain!

Chest Pain

  Can be non-cardiac   Inflammatory disorders   Musculoskeletal   Trauma   Drug therapy   Indigestion   Anxiety

  Can’t always tell cause of pain from Hx but usually can determine if is from chest wall, pleura, or viscera

Chest Pain

  Pulmonary causes usually result of disease involving chest wall or parietal pleura = pleuritic pain

  “Inspirational pain” is sharp, abrupt in onset, often severe

  Causes

1/25/09

11

Chest Pain

  Chest wall pain   Originates

  from intercostal & pectoral muscles, ribs, cartilage   stimulation of neural pathways

  Well-localized, constant soreness, increases with direct pressure or arm movements

  Remember, pain is subjective

  Perception varies with   Source   Previous experience   Culture   Personality traits   Amount of rest   Emotional implication of the pain

Chest Pain

Chest Pain

  Be careful in history to ascertain   Onset   Location   Radiation,   Frequency   Duration   Severity   Precipitating & relieving factors   Description

1/25/09

12

Dizziness, Syncope

Dizziness, Syncope

  = temporary loss of consciousness

  Caused by reduced blood flow &/or O2 to the brain

  Can be localized or generalized

Dizziness, Syncope

Non-pulmonary Pulmonary

Embolism PTE

Hemorrhage Pulm hypertension

ASVD Coughing fits

Hypovolemia Hypoxia

Hypotension Hypercarbia

1/25/09

13

Dizziness, Syncope

  Activity that precedes episodes gives clues to cause, i.e.   During or after exercise suggest pulm hypertension   Irregular heart rate, palpitations suggest cardiac

dysrhythmias

Dizziness, Syncope

  Vasovagal syncope

  Orthostatic hypotension

  Carotid sinus syncope

  Cough (tussive) syncope

Edema

1/25/09

14

Edema

  = soft tissue swelling due to abnormal accumulation of fluid

  May be generalized, localized or dependent

  May be limited to 1 organ

  Assoc. with kidney, liver, pulm, cardiac disease; obstruction of lymphatic drainage flow

Edema not relieved

by rest, elevation

Edema of abdominal

organs, skin breakdown

Pulmonary

edema

Left heart

failure

death

Edema is 1st dependant

relieved by rest, elevation

Venous blood

flow impeded

Fails

Enlarges

Right heart has

to pump harder

Pulmonary

vasoconstriction

Hypoxia

Hypercarbia

Acidosis

Lung

disease

Edema

  Rated on a scale of 0 to +4 based on refill time   “pitting” edema   0 – no edema/+4 - >2 minutes

  Edema = sign & symptom

1/25/09

15

Fever, Chills, Night Sweats

Fever, Chills, Night Sweats

  Affected by age, exercise, excitement, sudden changes in environmental temp, route of measurement

  Fever (hyperthermia, pyrexia) = temp above normal   Sustained   Remittent   Intermittent   Relapsing

Fever, Chills, Night Sweats

  Is a nonspecific symptom caused by a multitude of origins   Hot environment   Dehydration   Reaction to chemical substances, drugs   Protein breakdown   Damage to hypothalamus   Malignant neoplasms   Connective tissue damage   ** infection **

1/25/09

16

Fever, Chills, Night Sweats

  Is a concern for 2 reasons: 1.  Significant disease is present 2.  Increases metabolic rate which increases O2

requirement and CO2 production

Fever, Chills, Night Sweats

  Fever usually accompanied by aching, malaise, irritability, incr HR → confusion, delirium, convulsions

  If fever increases rapidly - may be accompanied by chills, shivering, rigors

  Normal to incr sweat prod x 3 with drop in body temp @ night   If temp falls rapidly - sweat prod x 5-8 → diaphoresis

= night sweats

Fever, Chills, Night Sweats

  Since fever is the most common manifestation of infections, it should be assumed to be caused by an infectious process until proven otherwise

  On the other hand, it cannot be assumed that the patient does not have an infection because there is no fever   Can have massive infection without fever if

  Taking high-dose steroids   Have compromised immune system

  Fever can be a symptom or sign

1/25/09

17

Headache, Altered Mental Status, Personality Changes

Headache, Altered Mental Status

  Decr O2 &/or incr CO2 in blood → headache

decr O2 to systemic

brain vasodilation

↓ ↓

cerebral cerebral

hypoxia vasodilation

Headache, Altered Mental Status

  If persists - changes in mental status Thought processes & memory deterioration Mind wanders Easily distracted

↓ Tremors Uncontrolled movements Hallucinations Nightmares

↓ drowsiness, disorientation, coma → death

1/25/09

18

Headache, Altered Mental Status

  Personality changes are not uncommon   Forgetfulness, inability to concentrate

  Family may report patient is   Depressed, anxious, irritable, demanding, in denial,

refusing to follow treatment regimens

  As disease progresses, lifestyle options change   Choices in places to work, play & live decrease   Dependency on others increase   Result???

Headache, Altered Mental Status

  When these changes occur suddenly = acute problem

  Can be result of many factors -- but could be hypoxia, hypercarbia

  Always think this and rule out