CAPSULAR PATTERN OF JOINT

Capsular
Joint
Pattern
Temporomandibular Opening
Extension &
side flexion
Occipitoatlanto
equally
limited
Side flexion &
rotations
Cervical Spine equally
limited,
extension
Lateral
rotation,
Glenohumeral abduction,
medial
rotation
Pain at
extreme
Sternoclavicular
range of
movement
Pain at
extreme
Acromioclavicular
range of
movement
Flexion,
Humeroulnar
extension
Flexion,
extension,
Radiohumeral
supination,
pronation
Supination,
Proximal Radioulnar
pronation
Pain at
Distal Radioulnar extremes of
rotation
Wrist Flexion &
extension
equally
 limited
Abduction,
Trapeziometacarpal
extension
Flexion,
MCP and IP
extension
Side flexion &
rotation
Thoracic Spine equally
limited,
extension
Side flexion &
rotation
Lumbar Spine equally
limited,
extension
Pain when
SI, Symphysis Pubis, & Sacrococcygeal joints
stressed
Flexion,
Abduction,
Hip medial
rotation
(order varies)
Flexion,
Knee
extension
Pain when
Tibiofibular
joint stressed
Plantar
Talocrural flexion,
dorsiflexion
Limitation of
Subtalar (Talocalcaneal) varus range
of movement
Dorsiflexion,
plantar
flexion,
Midtarsal
adduction,
medial
rotation
Extension,
First MTP
flexion
Second to Fifth MTP Variable
Flexion,
IP
extension

GENERAL CARDIO-RESPIRATORY ASSESSMENT

Adult Cardio-Respiratory Assessment

The following assessment must be completed and documented. As a complete respiratory exam
includes a cardiovascular exam, these two examinations have been combined.

ASSESSMENT

History of Present Illness and Review of Systems

General

The following characteristics of each symptom should be elicited and explored:

Onset sudden or gradual

Location - radiation

Duration frequency, chronology

Characteristics quality, severity

Associated Symptoms

Aggravating and precipitating factors

Relieving factors

Current situation (improving or deteriorating)

Effects on ADLs

Previous diagnosis of similar episodes

Previous treatments and efficacy of

Cardinal Signs and Symptoms

In addition to the general characteristics outlined above, additional characteristics of specific

symptoms should be elicited, as follows:

Cough

Quality (e.g., dry, hacking, loose, productive)

Severity

Timing (e.g., at night, with exercise, in cold air, outside or inside)

Duration: greater than 2 weeks (screen for TB)

Sputum

Colour

Amount (in teaspoons, tablespoons, cups)

Consistency

Purulence, odour, foul taste

Time of day, worse

Hemoptysis

Amount of blood

Frank blood or mixed with sputum

Association with leg pain, chest pain, shortness of breath

Shortness of Breath

Exercise tolerance (number of stairs client can climb or distance client can walk)

Relation to posture

Orthopnea (number of pillows used for sleeping)

Shortness of breath at rest

Association with paroxysmal nocturnal dyspnea (waking up out of sleep, acutely short of breath;
attack resolves within 20 to 30 minutes of sitting or standing up)

Associated swelling of ankles or recent weight gain

Cyanosis

Observation of blue colour of the lips or fingers (under what circumstances, when first noted, recent
change in this characteristic)

Wheeze

Timing (i.e., at rest, at night, with exercise)

Chest Pain (see table 1)

Associated symptoms (i.e., faintness, shortness of breath, nausea)

Relation to effort, exercise, meals, bending over

Explore the pain carefully. Include quality, radiation, severity, timing, quality.

Fainting or Syncope

Weakness, light-headedness, loss of consciousness

Relation to postural changes, vertigo or neurological symptoms

Extremities
 Edema:

- site (i.e., in dependent body parts)

- relation of edema to activity or time of day

Intermittent claudication (exercise-induced leg pain)

- distance client can walk before onset of pain related to claudication

- time needed to rest to relieve claudication

- temperature of affected tissue (warm, cool or cold)

Tingling

Leg cramps or pain at rest

Presence of varicose veins

Other Associated Symptoms

Fever

Malaise

Fatigue

Night sweats

Weight loss

Palpitations

Nausea and vomiting

GI Reflux

Medical History (Specific to Cardio-respiratory Systems)

Allergies

Medications currently used (prescription and over the counter [e.g., angiotensin-converting enzyme
(ACE) inhibitors, -blockers, ASA, steroids, nasal sprays and inhaled medications (puffers,
antihistamines, estrogen, progesterone, diuretics, antacids, steroids, digoxin)]
Herbal/traditional preparations

Immunizations (e.g., pneumococcal, annual influenza)

Disorders:

- Frequency of colds and treatment used, nasal polyps, chronic sinusitis

- Asthma, bronchitis, pneumonia, chronic obstructive pulmonary disease (COPD), tuberculosis (TB)
(disease or exposure), cancer, cystic fibrosis

- Dyslipidemia, hypertension, diabetes mellitus, thyroid disorder, chronic renal disease, systemic lupus
erythematosus
- Coronary artery disease, angina, myocardial infarction

- Cardiac murmurs, valvular heart disease

- Recent viral illness, history of rheumatic fever

Seasonal allergies

Presence of symptoms of gastro-oesphageal reflux disease (GERD)

Admissions to hospital and/or surgery for respiratory or cardiac illness

Date and result of last Mantoux test and chest x-ray

Blood transfusion

Family History (Specific to Cardio-respiratory Systems)

Others at home with similar symptoms

Allergies, atopy

Asthma, lung cancer, TB, cystic fibrosis

Diabetes mellitus

Heart disease: hypertension, ischemic coronary artery disease, MI (especially in family members <
50 years of age), sudden death from cardiac disease, dyslipidemia, hypertrophic cardiomyopathy

Personal and Social History (Specific to Cardio-respiratory Systems)

Smoking history (number of packages/day, number of years)

Exposure to second hand smoke, wood smoke

Substance use alcohol, caffeine, street drugs, including injection drugs, cocaine, steroids

Occupational or environmental exposure to respiratory irritants (mining, forest fire fighting)

Exposure to pets

Crowded living conditions

Poor personal or environmental cleanliness

Institutional living

Injection and inhaled drug use

Alcohol use

HIV risks

Mold

Obesity

High stress levels (personal or occupational)

PHYSICAL ASSESSMENT

Vital Signs

Temperature

Pulse

Respiratory rate

Blood pressure

Sp02

General Appearance

Acutely or chronically ill

Degree of comfort or distress

Position to aid respiration (e.g., tripod)

Diaphoresis

Ability to speak a normal-length sentence without stopping to take a breath

Colour (e.g., flushed, pale, cyanotic)

Nutritional status (obese or emaciated)

Hydration status

Inspection

Colour (e.g., central cyanosis)

Shape of chest (e.g., barrel-shaped, spinal deformities)

Symmetry of chest movement

Rate, rhythm and depth of respiration, respiratory distress

Use of accessory muscles (sternocleidomastoid muscles)

Intercostal indrawing

Evidence of trauma

Chest wall scars, bruising, signs of trauma

Clubbing of the fingers

Precordium: visible pulsations

Jugular venous pressure

Color of conjunctiva

Extremeties
- Hands - edema, cyanosis, clubbing, nicotine stains, cap refill (<3 seconds)

- Feet and legs - changes in foot colour with changes in leg position (i.e., blanching with elevation,
rubor with dependency), ulcers, varicose veins, edema (check sacrum if client is bedridden), colour
(pigmentation, discoloration), distribution of hair

Skin - rashes, lesions, xanthomas

Palpation

Tracheal position (midline)

Chest wall tenderness

Respiratory Excursion

Tactile fremitus

Spinal abnormality

Nodes (axillary, supraclavicular, cervical)

Masses

Subcutaneous emphysema

Apical beat:

- PMI normally located at the fifth intercostal space, mid-clavicular line

- Assess quality and intensity of apical beat normal, diffuse, weak, forceful, heave

- Apical beat (PMI) may be laterally displaced, which indicates cardiomegaly

Identify and assess pulsations and thrills (palpable murmur that feels like a purr) in aortic, pulmonic,
mitral and tricuspid areas, along left and right sternal borders, in epigastrium and along left anterior
axillary line

Hepatomegaly, RUQ tenderness

Peripheral pulses

- Check for presence, rate, rhythm, amplitude and equivalence of peripheral pulses, (radial, brachial,
femoral, popliteal, posterior tibial, dorsalis pedis)

- Check for synchrony of radial and femoral pulses

Edema: pitting (rated 0 to 4) and level (how far up the feet and legs the edema extends); sacral
edema

Skin: temperature, turgor, texture

Percussion of lung fields

Resonance

- Increased resonance over hyperinflated areas (e.g., asthma, emphysema)

- Dullness to percussion over areas of consolidation (e.g., pneumonia, pleural effusion and collapsed
lung)
 Location and excursion of the diaphragm

Auscultation of lungs

Assist client to breathe effectively

Listen for sounds of normal air entry before trying to identify abnormal sounds

Degree of air entry throughout the chest (should be equal)

Quality of breath sounds (e.g., bronchial, bronchovesicular, vesicular)

Ratio of inspiration to expiration (prolonged expiration in asthma, COPD)

Adventitious Sounds:

- Wheezes (aka rhonchi): continuous sounds, ranging from a low-pitched snoring quality to a high-
pitched musical quality, may be inspiratory or expiratory, or both, may clear with coughing, may be
present only on forced expiration.

- Crackles (aka rales): discrete, crackling sounds heard on inspiration, may clear with coughing. May
be fine (high-pitched, short popping sounds) or coarse (low-pitched, bubbling and gurgling sounds).
Diffuse in severe pneumonia, bronchiolitis, CHF. Localized in bronchiectasis and pneumonia.

- Pleural rub: a coarse, creaking sound from pleural irritation, heard on inspiration or expiration

- Stridor: high-pitched, inspiratory, crowing sound louder in the neck.

- Pleural rub: pneumonia, effusion

- Decreased breath sounds: pneumonia, atelectasis, pleural effusion, pneumothorax

Auscultation of heart

Listen to normal heart sounds before trying to identify murmurs. Use diaphragm of stethoscope first,
then bell of stethoscope, when listening to the heart

Auscultate at aortic, pulmonic, Erbs point, tricuspid, and mitral. Attempt to identify:

- Rate and rhythm.

- S1 and S2 sounds and their intensity

- Added heart sounds (S3 and S4), rubs, splitting of S2

- Murmurs: determine location (where murmurs are best heard), radiation, their timing in cardiac cycle,
intensity (grade; seeTable 1) and quality

Auscultate carotid arteries, abdominal aorta, renal arteries, iliac arteries, and femoral arteries for
bruits

Table 1. Grade of Heart Murmur

Grade Characteristics

I
Very quiet, barely audible
II
Quiet but audible
III
Easily heard
IV
Thrill can be felt, murmur is easily heard
V
Thrill can be felt and loud murmur can be heard with stethoscope placed lightly on chest
VI
Thrill can be felt and very loud murmur can be heard with stethoscope held close to chest wall

Associated Systems

Ear, Nose, Throat

A complete respiratory assessment includes the ENT system.

CLINICAL REASONING AND CLINICAL JUDGMENT

The first step is to differentiate between acute respiratory distress and respiratory conditions that can
be managed safely by certified practice nurses.

The following signs and symptoms require immediate referral to a physician or nurse practitioner:

Severe dyspnea

Unable to lay flat

Inability to speak or fragmented speech

Tracheal shift

Unrelieved chest pain

Unable to maintain Sp02 greater than > 92% on room air

Severe increasing fatigue

Cyanosis (central cyanosis is not detectable until SaO2 is less than 85%)

Silent chest or crackles throughout lung fields

Decreased level of consciousness

Diminishing respiratory effort

Nasal flaring or tug

Intercostal indrawing

Pulsus paradoxus

Pitting edema of extremities

Recent MI

Recent hospitalization for Congestive Heart Failure (CHF)

DIAGNOSTIC TESTS:
 The certified practice nurse may consider the following diagnostic tests in the examination of the
cardio-respiratory system to support clinical decision making:

- ECG

- Hemoglobin

- Cardiac troponins
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Relaxation based on Laura Mitchell Technique

Relaxation based on Laura Mitchell Technique
Make sure you are lying comfortably on your back with nothing tight around your
waist or neck; your head well supported, you hands at your side; palms
downwards.
Ensure you will not be distracted.
This time is for you to put aside and concentrate on your relaxation exercise.
Ready..
Be aware of your body resting and being fully supported by the floor.
Be aware of your breathing, comfortably and easily, your abdomen rising and
falling as you breathe.
Your Shoulders:
SLIDE your hands along the floor down towards your knees, pulling your
shoulders down. Stop pushing and let go. .Repeat
THINK about the movement.
FEEL the new position of the shoulder joints, feel them loose and down.
Your Elbows:
MOVE your elbows a little away from your sides. Stop .Repeat
THINK about the movement.
FEEL the length on your fingers, the looseness of your hand.
Your Legs:
TURN your hips outwards, rolling the kneecaps away from each other, out to the
sides. Stop pressing and let go. .Repeat
THINK about the movement.
FEEL the looseness of your hips, the softness of your buttocks and stomach.
Your Knees:
MOVE your knees until they feel comfortable and then stop.
THINK about the movement.
FEEL your knees lying comfortable supported by the floor.
Your Feet and Ankles:
PUSH your feet away from your hips, gently curling the toes under. Stop
.Repeat
THINK about the movement.
FEEL your feet resting at the ends of your legs.
Now that you have produced relaxation in the muscles of your arms and legs,
just enjoy the sensation of your limbs resting. Check your breathing is gentle,
maybe sighing from time to time as you breathe out.
Your Body:
PUSH your body down into the floor along the length of the spine. Stop and let
go .Repeat
THINK about the movement.
FEEL the floor holding the weight of your body. You have transferred all your
body weight to the floor.
Your Head:
PRESS your head straight down into the floor, pulling in the chin. Stop and let
go .Repeat
THINK about the movement.
FEEL the tightness flowing out.
Your Face:
CLOSE the lips and teeth. Keeping the lips gently touching, inside the mouth
part the teeth, pulling the jaw down. When your teeth are comfortably
separated and you feel your heavy jaw hanging loosely inside your mouth, Stop
.Repeat
THINK about the movement.
FEEL the looseness of your lips and jaw.
Your Forehead:
RAISE the eyebrows up to the hairline. Let your brows rest and find their own
level.Repeat
THINK about the movement.
FEEL the smoothness of your forehead.
Your Eyes:
You may have already closed your eyes. If they are open, gently hold them
closed, not held tightly shut, just gently closed.
THINK about each part of your body now without any movement.
Gradually become aware of your breathing, notice how slow and gentle it is.
Be aware of your body, notice if any of areas of tightness or discomfort have
changed.
Become aware of your surroundings again.
Slowly open your eyes. Give a good stretch to your arms and legs and get up
when you are ready.
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GOOD BREATHING GUIDE

Good Breathing Guide

Breathing well means moving air in and out of the chest
with the minimum of effort and the correct muscles. This
is to give you the right balance of oxygen and carbon
dioxide you need to live and feel well.

The most important muscle used for your breathing is the DIAPHRAGM.

The diaphragm is a strong flat muscle, which is attached to the lower

edges of the ribs.

It separates the chest from the gut.

It is shaped like a dome of an umbrella when relaxed.

As you breathe IN it contracts and moves downwards, drawing air into

your lungs. This causes your tummy to expand and rise.

As you breathe OUT the diaphragm moves upwards, expelling the air
from your lungs.

Breathing-well also involves your lower ribs, which flare out gently,
helping the diaphragm while the upper ribs remain relaxed.
 It is only during increased activity that the upper chest
opens up to draw in extra air that it needs. This can also
happen when you are stressed.

Should I breathe through my nose or my mouth?

It is very important that you breathe in and out through

your nose to allow the air to be filtered, warmed and
moistened. It is ok to breathe through your mouth when
you are exercising.
How slowly should I breathe?
At rest you should only be taking between 8-
12 breaths in a minute.
When you are practising have a count of how
many breaths you take in one minute.

How do I practise the Good Breathing'

technique?
Get yourself into a comfortable position (start by lying with pillows to
support you under your head and knees)

Breathe in gently through your nose, feel your tummy rise and expand
'like a balloon' as you breathe in.

Let the air 'fall' out of your chest without pushing. Breathe out lightly.

Make sure you relax and pause at the end of each breath out

When you breathe in, your upper chest should be relaxed and not
moving. Place your hand on your upper chest to check this. You can
 also place your hand on your tummy and feel it moving or place an
object on your tummy and watch it rise and fall e.g. box of tissues.

Practise your breathing-well technique as often as you can. Once you

have it correct in lying try it in different positions, like sitting & standing.
Sitting can
sometimes be the hardest position to get it right in so keep working at it.

Practise for a total of one hour a day, choose how you make up this
hour, for example 5 minutes every hour or 4 lots of 15 minutes or two
lots of half an hour. Work out which is the best for you that you can work
into your day.

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EXERCISE FOR SHOULDER STRENGTHNING

GENERAL CARDIO-RESPIRATORY ASSESSMENT

Adult Cardio-Respiratory Assessment The following assessment must be completed and documented. As a complete
a c...

STUMP BANDAGING FOR ABOVE AND BELOW KNEE AMPUTATION

STUMP BANDAGING TECHNIQUE FOR ABOVE KNEE AMPUTATION STUMP BANDAGING TECHNIQUE FOR BE
AMPUTATION...


Exercise for Ankle and Foot/Exercise for Plantar fasciitis/Exercise for Calcaneal spur

Exercise for Herniated disc/ Exeercise for disc prolapse/exercise fo slipped disc.

EXERCISE FOR SACROILIAC PAIN SYNDROME

DUMBBELL WORKOUT FOR SHOULDER MUSCLES/UPPER BODY

KINESIO TAPING FOR PATELLAR TENDINITIS/INFRA PATELLAR BURSITIS/ FAT PAD SYNDROME

CHEST WORKY OUT/ GYM TRAINING FOR CHEST MUSCLES/EXERCISE BODY BUILDERS
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