Remote Nursing Certified Practice
Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT
This assessment is based on best practice as of February 2012. For more information or to provide
feedback on this or any other decision support tools, e-mail certifiedpractice@[Link]
ADULT CARDIO-RESPIRATORY ASSESSMENT
Nurses with Remote Nursing Certified Practice (CP) designation are able to manage the
following respiratory condition:
Acute bronchitis
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
Aggravating and precipitating factors
Relieving factors
Current situation (improving or deteriorating)
Effects on Activities of Daily Living (ADL)
Previous diagnosis of similar episodes
Previous treatments and efficacy
Cardinal Signs and Symptoms
In addition to the general characteristics outlined above, additional characteristics of specific
symptoms should be elicited, as follows:
Cough
Quality
Severity
Timing
Duration: greater than 2 weeks (screen for Tuberculosis (TB))
Sputum
Colour
CRNBC monitors and revises the CRNBC certified practice decision support tools (DSTs) every two years and as necessary based
on best practices. The information provided in the DSTs is considered current as of the date of publication. CRNBC-certified nurses
(RN(C)s) are responsible for ensuring they refer to the most current DSTs.
The DSTs are not intended to replace the RN(C)'s professional responsibility to exercise independent clinical judgment and use
evidence to support competent, ethical care. The RN(C) must consult with or refer to a physician or nurse practitioner as
appropriate, or whenever a course of action deviates from the DST.
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Remote Nursing Certified Practice
Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT
Amount
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)
Posture orthopnea or tripoding
Shortness of breath at rest
Association with Paroxysmal Nocturnal Dyspnea (PND)
Associated swelling of ankles or recent weight gain
Cyanosis
Central, peripheral
When, any recent changes
Wheeze
Timing
Chest Pain
Associated symptoms (Appendix 2)
Relation to effort, exercise, meals, bending over
Explore the pain carefully include quality, radiation, severity, timing
Fainting or Syncope
Weakness, light-headedness, loss of consciousness
Relation to postural changes, vertigo or neurological symptoms
Extremities
Edema:
- site
- 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
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Remote Nursing Certified Practice
Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT
Fatigue
Night sweats
Weight loss
Palpitations
Nausea and vomiting
Gastro intestinal reflux
Medical History Specific to Cardio-respiratory Systems
Allergies, including seasonal and environmental
Medications currently used (prescription and Over The Counter (OTC) e.g., angiotensinconverting enzyme (ACE) inhibitors, -blockers, Acetyl Salicylate Acid (ASA), steroids,
nasal sprays and inhaled medications (puffers), antihistamines, hormones, diuretics,
antacids, steroids, digoxin)
Herbal/traditional preparations
Immunizations (e.g., pneumococcal, annual influenza)
Medical conditions:
- Frequency of colds and respiratory infections, recent viral illness, joint pain or swelling
- History of rheumatic fever
- Nasal polyps, chronic sinusitis, asthma (Appendix 1), bronchitis, pneumonia, Chronic
Obstructive Pulmonary Disease (COPD), TB (disease or exposure), cancer, cystic fibrosis
- Dyslipidemia, hypertension, diabetes mellitus, thyroid disorder, chronic renal disease,
systemic lupus erythematosus
- Coronary Artery Disease (CAD), angina, Myocardial Infarction (MI)
- Cardiac murmurs, valvular heart disease
- Downs Syndrome
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 (Appendix 1), lung cancer, TB, cystic fibrosis, bronchitis
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, pets, mould
Crowded living conditions
Poor personal or environmental cleanliness
High stress levels (personal or occupational)
Institutional living
Occupational or environmental exposure to respiratory irritants (mining, forest fire fighting)
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Remote Nursing Certified Practice
Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT
Substance use (e.g., alcohol, caffeine, street drugs, including injection and inhaled drugs /
solvents)
Human Immunodeficiency Virus (HIV) risks
Obesity
Immigration or travel abroad
PHYSICAL ASSESSMENT
Examination of the ear, nose, and throat should also be carried out because of the
interrelatedness between these systems and structures and the functioning of the lower
respiratory tract
Vital Signs
Temperature
Pulse
Respiratory rate
SpO2
Blood pressure (BP)
Peak flow
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
Nutritional status
Hydration status
Mental status
Inspection
Colour, cyanosis
Shape of chest
Symmetry of chest movement
Rate, rhythm and depth of respiration, respiratory distress
Intercostal indrawing
Use of accessory muscles
Precordium: visible pulsations
Chest wall scars, bruising, signs of trauma
Jugular Venous Pressure (JVP)
Color of conjunctiva
Extremities
- Hands edema, cyanosis, clubbing, nicotine stains, cap refill <3 seconds
- Feet and legs changes in foot color 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
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Remote Nursing Certified Practice
Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT
Skin rashes, lesions, xanthomas
Palpation
Tracheal position (midline)
Chest wall tenderness or crepitus
Respiratory excursion
Tactile fremitus
Spinal abnormality
Nodes (axillary, supraclavicular, cervical)
Masses
Apical beat:
- Point of Maximum Impulse (PMI) normally located at the fifth intercostal space, midclavicular line
- Assess quality and intensity of apical beat
- Apical beat (PMI) may be laterally displaced, which indicates cardiomegaly
Identify and assess pulsations and thrills
Hepatomegaly, Right Upper Quadrant (RUQ) tenderness
Assess 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
Percussion of lung fields
Resonance
- Increased resonance over hyperinflated areas
- Dullness to percussion over areas of consolidation
- Location and excursion of the diaphragm
Auscultation of lungs
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
Adventitious sounds:
- Wheezes (rhonchi), crackles (rales), pleural rub, stridor, decreased breath sounds.
Auscultation of heart
Listen to normal heart sounds before trying to identify murmurs
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
- Murmur
- Auscultate carotid arteries, abdominal aorta, renal arteries, iliac arteries, and femoral
arteries for bruits
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Remote Nursing Certified Practice
Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT
Associated Systems
A complete respiratory assessment includes the Ear, Nose and Throat (ENT) system
Consider Gastro Intestinal (GI)/Genito-Urinary (GU) assessment if appropriate
SYMPTOMS REQUIRING URGENT REFERRAL OR CONSULTATION
The first step is to differentiate between acute respiratory distress and respiratory
conditions that can be managed safely by certified practice nurses.
New onset of the following signs and symptoms require immediate emergency care and
referral to a physician or nurse practitioner:
Severe dyspnea and inability to lay flat
Inability to speak or fragmented speech
Tracheal shift
Unrelieved chest pain
Unable to maintain SpO2 greater than > 92% on room air
Severe increasing fatigue
Cyanosis (central cyanosis is not detectable until oxygen saturation is less than 85%)
Silent chest or crackles throughout lung fields
Decreased level of consciousness
Diminishing respiratory effort
Nasal flaring or tug
Intercostal indrawing
Recent hospitalization for Congestive Heart Failure (CHF)
Diagnostic Tests:
The remote CP nurse may consider the following diagnostic tests in the examination of the
cardio- respiratory system to support clinical decision making:
- Electrocardiogram (ECG)
- Hemoglobin (Hb)
- Cardiac troponins
- Sputum for Culture and Sensitivity (C&S)
REFERENCES
Dugani, S., & Lam, D. (Eds.). (2009). The Toronto Notes 2009 Comprehensive Medical
Reference & Review for MCCQE 1 & USMLE II. Toronto, Canada: Toronto Notes for
Medical Students, Inc.
Estes, Mary Ellen Zator. (2010). Health Assessment & Physical Assessment, 4th Ed. Clifton
Park, NY: Delmare, Cengage Learning
First Nations, Inuit and Aboriginal Health. (2010). Clinical Practice Guidelines for Nurses in
Primary Care. Retrieved March 26, 2012 from [Link]
Jarvis, C. (2009). Physical examination and health assessment: First Canadian Edition. Toronto,
ON: Elsevier Canada.
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Remote Nursing Certified Practice
Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT
Leblond, R., Brown, D., & DeGowin, R. (2009). DeGowins diagnostic examination. New York:
McGraw-Hill Medical.
Provincial Health Services Authority. (2009). Emergency Services Asthma Protocol Toolkits
Retrieved March 26, 2012 from [Link]
Stephen, T., Skillen, D., Day, R., & L. Bickley. (2010). Canadian Bates Guide to Health
Assessment for Nurses. Philadelphia, PA: Lippincott, Williams and Wilkins.
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Remote Nursing Certified Practice
Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT
Appendix I
From PHSA (2009) Emergency Services Asthma Protocol Toolkits published online for each health authority at
[Link]
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Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT
Remote Nursing Certified Practice
Appendix II Characteristics of Chest Pain
Characteristic
Myocardial
MSK Disorder
Esophageal,
Stress or
of Chest Pain
Infarction or
Angina
Pneumonia
Pulmonary
Embolism
(chest wall
Gastric or
Emotional
pain)
Duodenal
Disorder
Acute
(Chest pain may
Coronary
be absent in
Insufficiency
pulmonary
Pericarditis
Bronchitis
Dissecting Aortic
Aneurysm
Disorder
embolism)
Onset
Location
Sudden, patient With exertion
Gradual or
at rest
sudden
Sudden
Gradual or
Gradual or
sudden
sudden
Gradual or sudden
Gradual or sudden Gradual
Sudden
Retrosternal,
Retrosternal,
Retrosternal,
Anterior,
Retrosternal,
Retrosternal,
Anterior,
Retrosternal,
Variable; anterior
Muscular
anterior chest
anterior chest
lateral
anterior chest,
anterior chest
lateral and/or
epigastric, left
chest, left chest
ache in chest epigastric, back,
and/or
lateral chest
posterior chest
chest, left or right
wall
upper quadrant
posterior
wall
anterior chest,
lung field(s)
Radiation
Left arm, left
Left arm, left
abdominal
Variable:
Arm, shoulder, May be felt in back Usually none
shoulder, neck, shoulder, neck,
chest,
shoulder tip,
neck, back,
jaw, back,
shoulder,
neck
abdomen
jaw, back,
Anterior
posterior and / or
Variable
Usually none Often radiates to
or arm
thoracic back, or
abdomen
upper abdomen upper abdomen neck
Duration
> 20 min
Usually < 1-2
Hours
Variable
Hours to days Minutes or
min
Minutes or hours
Minutes or hours
hours
Hours to
>20 minutes to
days, usually hours
with
coughing
Intensity
Severe
Mild to
Moderate
moderate
Absent or mild
Usually
to moderate
moderate, but moderate
Mild to
Moderate
Mild to moderate
Mild to
Excruciating.
moderate
may be severe
Quality
Sensation of
Sensation of
Constant
Dull ache;
squeezing,
tightness,
ache, with
knifelike pain
Sharp
Dull ache;
sharp pain may tightness
Burning (usually),
pressure
pressure
intermittent
may also be
also be present
knife-like
present
pain
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Achy, stabbing
Aching
Knifelike, tearing.
May be nagging.
Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT
Remote Nursing Certified Practice
Characteristic
Myocardial
Angina
Pneumonia
Pulmonary
of Chest Pain
Infarction or
Acute
Coronary
be absent in
Insufficiency
pulmonary
Pericarditis
MSK Disorder
Esophageal,
Stress or
Embolism
(chest wall
Gastric or
Emotional
(Chest pain may
pain)
Duodenal
Disorder
Bronchitis
Dissecting Aortic
Aneurysm
Disorder
embolism)
Relief
May be relief
Sitting up and Rest, mild
Antacids, milk,
Rest, relaxation,
Rest, control None
with sublingual with rest and/or
Rapid relief
None
None
leaning
sitting up or
distraction
of cough
nitroglycerin
sublingual
forward often
nitroglycerin
helps; other
Stressful
Cough
analgesics
standing up
changes in
position may
alter the pain
Precipitating or None may be
Exertion, heavy Increased
Immobilization,
Previous
History of
Certain foods, a
aggravating
meal, walking
pain with
estrogen or CA
infection of
unaccustomed
large meal, bending situations, fatigue
uphill against a
coughing or
therapy. None
upper
physical work;
over; pain may
cold wind,
deep
may be obvious. respiratory
pain worse
awaken person
occasionally
inspiration;
Pain may be
with arm action from sleep and may
from laying
recently ill
worse with deep worse with
occur when
down
with a cold
inspiration or
deep
stomach is empty
coughing
inspiration or
obvious
factors
tract; pain
Aortic aneurysm
(often unknown).
coughing
Associated
Nausea,
Fever,
Shortness of
Localized chest Regurgitation of
Tightness in neck
Malaise,
Widening pulse
signs and
sweating,
Typically none
cough,
breath, sweating, infection of
Symptoms of
wall
acid in mouth,
and shoulder(s),
fever, long
pressure,
symptoms
shortness of
sputum,
hemoptysis, leg
upper
tenderness,
belching, difficulty headaches,
standing
dissociation of
breath, anxiety,
shortness of
pain (rare), leg
respiratory
tender
swallowing,
reduced appetite,
productive
brachial blood
palpitations
breath,
edema
tract may be
costochondral
sticking sensation
mild weight loss,
cough,
pressures, absent
malaise,
present;
area
when food
fatigue, sleep
possibly
pulses,
fatigue
malaise;
swallowed, cough
disturbance,
wheezes in
hypotension
usually occurs
(rare); test of stool
palpitations,
chest
paralysis, pulsus
in younger
for occult blood
dizziness,
paradoxus, aortic
adults
may be positive
hyperventilation
insufficiency ,
symptoms
murmur.
Adapted from First Nations, Inuit and Aboriginal Health. 2010. Clinical Practice Guidelines for Nurses in Primary Care.
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