Oxygenation Assessment

1
Oxygenation Assessment

• Radial Pulse
• Using pads of first three fingers, palpate the
  radial pulses on each arm simultaneously. Feel
  for any differences in volume of pulse between
  arms.
• Feel pulse on one arm,
• note pulse pressure,
• note rhythm, before starting to count.
• If pulse is regular count for 30 seconds
  (Hollerbach Sneed 1990), if pulse is irregular
  count for full minute. Start count with zero

2
Pulse rate

• Normal rates
• Age Average Normal limits
• New-born 120 70-190
• 1 yr 120 80-160
• 12 female 90 70-110
• male 85 65-105
• 18 female 75 55-95
• male 70 50-90
• Athlete
• May be 50-60 50-100
• Adult 74-76 60-100
• Ageing 74-76 60-100
• Bradycardia is less than 60
• Tachycardia is more than 100

3
Pulse pressure

• Can be recorded as one of four-
• () Pulse is full or bounding
• () Pulse is normal
• () Pulse is weak or thready
• (0) Pulse is absent

4
Heart sounds

• are not usually ausculated but may be heard when
  taking an apex beat.
• An apex beat is heard at the 5th intercostal
  space at mid clavicular line. Apex beats and
  radial pulse should be identical in quantity.

5
The heart sound

• is typically described as a lub-dub.
• The first sound is the closing of the a-v valves
  (Tricuspid on the right and Mitral on the left).
  This occurs at the end of diastole, signalling
  the beginning of systole.
• The second sound is the semi-lunar valves closing
  (the pulmonary valve on the right and the aortic
  on the left).
• Further discrimination of the heart sounds is not
  usually carried out by UK nurses. The flow of
  blood through the heart usually makes no noise,
  therefore if murmurs are heard (a gentle blowing
  swooshing sound) these should be referred to a
  doctor.

6
Pulse Rhythm

• Should be an even tempo
• Note if irregularities are regularly irregular or
  irregularly irregular.
• Regularly irregular beats signify some form of
  heart block.
• Irregularly irregular beats are either multiple
  ventricular ectopics or AF.
• It is particularly important to notice changes of
  rhythm.

7
Sinus Arrhythmia

• The rate of the pulse may alter with respiration
  especially in children and young adults. The
  pulse may speed up at the end of inspiration and
  slow down to normal with expiration. It is called
  Sinus Arrhythmia and is normal.

8
Water-Hammer pulse

• Greater than normal force () then collapsing
  suddenly.
• Signifies Aortic valve damage with regurgitation
  back into the ventricle.

9
Pulsus Bigeminus

• Rhythm is coupled, every other beat comes early
  or a normal beat followed by a premature beat.
  The force of the premature beat is decreased due
  to shortened cardiac filling time.
• Signifies a conduction disturbance, e.g.
  premature ventricular contraction, may be
  associated with digitalis toxicity.

10
Pulsus Alternans

• The pulse has a regular rhythm but the force of
  the beat varies with alternating beats.
• Signifies left sided congestive cardiac failure.

11
Pulsus paradoxus

• The force of the pulse, or pulse pressure changes
  with breathing. Beats are weaker with
  inspiration, stronger with expiration. During BP
  measurement the systolic pressure drops by 10 mm
  Hg or more during inspiration.
• Signifies cardiac tamponade constrictive
  pericarditis.

12
Peripheral pulses

• Carotid artery pulse
• The carotid artery is located in the groove
  between the trachea and the sternomastoid muscle.
• Femoral pulse
• Popliteal pulse
• Pedal pulses

13
Veins

• The Jugular Vein
• The jugular vein reflects any increase in
  pressure in the right atrium. The jugular vein
  should be viewed with the patient at 45. Remove
  the upper -most pillow to avoid flexing the neck.
  The vein should not be visible.
• Unilateral distension is due to some local cause
  e.g. Kinking or aneurysm.
• Bilateral distension signifies increased central
  venous pressure and elevated pressure of more
  than 3 cm above sternal angle occurs with RHF.

14
Ask about any-

• Chest pain
• location, character, onset and duration, what
  makes it worse/better.
• Dyspnoea
• onset and duration? Nocturnal, ?positional. Does
  it interfere with ADLs?
• How many pillows do you use at night?
• Cough
• duration, frequency, type, any expectoration?
  What does it look like?
• Fatigue
• Do you tire easily? Onset? Gradual or sudden
• Nocturia
• No. of times
• Risk factors
• Smoking, alcohol, exercise, nutrition, drugs.

15
Observe-

• Cyanosis or pallor
• Oedema
• Where? When first noticed? Time of day? Equality
  of swelling

16
Peripheral flow

• Ask about any -
• Pain or leg cramps
• Describe, onset duration better/worse
• Skin changes on arms or legs
• colour and temperature
• drugs

17
Observe-

• Nails
• clubbing, spooning
• Blanch nail beds -
• colour should return within 1-2 seconds
• delayed refill signifies vasoconstriction or
  reduced cardiac output.
• Temperature of hands
• cold clammy?
• Arms
• Look for any venous distension.

18
Observe-

• Legs
• Look for any venous distension
• Note hair distribution/loss
• presence of varicosities, ulcerations
• Colour of legs and feet
• Pallor may suggest arterial insufficiency.
• Dependant rubor a deep blue-red colour occurs
  with severe arterial insufficiency.
• Brown staining associated with venous
  insufficiency.
• Temperature of legs
• Feel temperature of peripheries using back of
  hand. N.B. compare like with like.

19
Pedal pulses

• posterior tibial
• on the posterior medial aspect or
• dorsalis pedis
• on the front of the foot
• Doppler may be used to detect flow.
• Check for oedema.

20
Blood Pressure

• Systolic is the maximum pressure felt on
  ventricular contraction.
• Diastolic is the pressure when the heart is
  resting.
• The pulse pressure is the difference between the
  two.
• Refer back to sessions on taking the blood
  pressure

21
Respirations

• Normally relaxed, regular automatic and silent.
• Try to count while maintaining the position for
  recording pulse, so that respirations not altered
  by awareness.

22
Ask about-

• cough
• Shortness of breath
• Chest pain with breathing
• past history of respiratory infections
• Cigarette smoking
• environmental exposures - coal or asbestos dust,
  farm dust, TB

23
Observe-

• Rate of respirations
• Eupnoea
• Usually 10 - 20 per minute
• Tachypnoea
• is rapid shallow breathing over 24 per minute.
• This is a normal response to fever, fear or
  exercise. But may indicate respiratory
  insufficiency, pneumonia, pleurisy
• Bradypnoea
• Slow breathing, a decreased regular rate of less
  than 10 per minute. May be drug induced,
  increased intracranial pressure and diabetic
  (insulin) coma.

24
Depth and Rhythm of respirations

• Cheyne-Stokes Respirations
• A cycle of waxing and waning respirations with a
  period of apnoea. Most commonly associated with
  CCF, but also found in renal failure, meningitis,
  raised ICP and drug overdoses.
• Hyperventilation
• An increase in rate and depth can occur normally
  in exertion and fear. Also occurs in diabetic
  ketoacidosis (Kussmauls respirations), hepatic
  coma, salicylate overdose, increase CO2 or
  decrease O2, lesions of the mid-brain.

25
Shape of chest

• should have anterior-posterior diameter
  approximately half of the transverse diameter. A
  ratio of 12
• Barrel chest signifies chronic emphysema.
• Note the position adopted to breath

26
Tactile fremitus

• can be felt over the main bronchi
• when thick bronchial secretions obstruct the
  airway
• In the presence of pleural inflammation
• In the presence of surgical emphysema, when there
  is air in the subcutaneous tissues.

27
Breath sounds

• Listen to normal air flow.
• Absence of sound no flow collapse of part of
  the lung or consolidation
• During normal tidal flow (NOT FORCED EXPIRATION)
• Wheezing (rhonchi) indicates narrowed airways as
  in e.g. asthma.
• Crackles (rales) indicates presence of retained
  secretions e.g. in pulmonary oedema pneumonia.

28
Laboratory findings

• RBC
• Male 4.6 to 6.2 x106mm3. Female 4.2 to 5.4
  x106mm3
• Haemoglobin
• Male 14.0 to 16.5 gm/dl. Female 12.6 to
  14.2 gm/dl
• Haematocrit
• Male 42 to 52 Female 37 to 47
• PaO2 12 to 15 kPa
• PaCO2 4.5 to 6 kPa