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Oxygenation Assessment


note rhythm, before starting to count. If pulse is regular count for 30 ... clubbing, spooning. Blanch nail beds - colour should return within 1-2 seconds ... – PowerPoint PPT presentation

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Title: Oxygenation Assessment

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
  • 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

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

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

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.

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

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

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.

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

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.

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

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

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

  • 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.

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.

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

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

  • 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.

  • 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
  • Temperature of legs
  • Feel temperature of peripheries using back of
    hand. N.B. compare like with like.

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.

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

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

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

  • 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.

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.

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

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

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.

Laboratory findings
  • RBC
  • Male 4.6 to 6.2 x106mm3. Female 4.2 to 5.4
  • 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
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