Transcript Egan Ch 15 Bedside Assessment of the Patient

Chapter 15
Bedside Assessment of the Patient
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Learning Objectives



Describe why patient interviews are
necessary and the appropriate techniques
for conducting an interview.
Identify abnormalities in lung function
associated with common pulmonary
symptoms.
Identify breathing patterns associated with
underlying pulmonary disease.
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Learning Objectives (cont.)



Differentiate between dyspnea and
breathlessness.
Identify terms used to describe normal and
abnormal lung sounds.
Describe the mechanisms responsible for
normal and abnormal lung sounds.
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Learning Objectives (cont.)


Explain why it is necessary to examine the
precordium, abdomen, and extremities in a
patient with cardiopulmonary disease.
Describe some of the common abnormalities
found during the exam of the precordium,
abdomen, and extremities in patients with
cardiopulmonary disease.
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Introduction




Bedside assessment—process of
interviewing & examining patient for signs &
symptoms of disease
Inexpensive & little risk to patient
Part of initial assessment to identify diagnosis
& to evaluate ongoing effects of treatment
2 key sources of patient data:


Medical history
Physical examination
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Interviewing
 Purposes



Establish rapport with patient
Obtain essential diagnostic information
Help monitor changes in patient’s symptoms &
response to therapy
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All of the following are reasons why a clinician
should review a patient’s medical history and
perform a physical examination, except:
A. Helps identify the need for subsequent
diagnostic tests
B. Helps select the best approach for therapy
C. Helps monitor patient’s progress toward
predefined goals
D. Determines how long the patient will remain in
the hospital
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Interviewing (cont.)
 Technique

Introduce yourself in social space (~4-12 feet)

Interview in personal space (~2-4 feet)

Use appropriate eye contact

Assume physical position at same level as patient

Avoid use of leading questions; use neutral
questions
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Interviewing (cont.)
 Common questions to ask for each symptom:





When did it start?
How severe is it?
Where on body is it?
What seems to make it better or worse?
Has it occurred before?
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Cardiopulmonary Symptoms
 Dyspnea
 Sensation of breathing discomfort by patient
(subjective feeling)
 Most important symptom RT is called upon to
assess & treat
 Breathlessness
 Sensation of unpleasant urge to breathe
 Can be triggered by acute hypercapnia, acidosis &
hypoxemia
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Cardiopulmonary Symptoms
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Cardiopulmonary Symptoms
 Dyspnea
 Subjective experience. Should not be inferred
from observing patient`s breathing pattern
 Orthopnea: dyspnea in reclining position;
associated w/ CHF
 Platypnea: dyspnea in upright position associated
w/ arteriovenous malformation
 Degree of dyspnea is evaluated by asking about
level of exertion at which it occurs
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Cardiopulmonary Symptoms (cont.)
 Language of Dyspnea
 Ask patient about quality & characteristics of
dyspnea (may provide insight into its causes)



Patients w/ asthma frequently complain of chest
tightness
Patients w/ interstitial lung disease may complain
of increased WOB, shallow breathing & gasping
Patients w/ CHF may complain of feeling
suffocated
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Cardiopulmonary Symptoms (cont.)
 Assessing dyspnea during an interview:

Pay attention to whether patient can speak in full
sentences
 Questions should be brief & limited to quality &
intensity of dyspnea & circumstances of symptom
onset
 Assessment should correspond with gross
examination of patient’s breathing pattern
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Cardiopulmonary Symptoms (cont.)
 Psychogenic Dyspnea: Panic Disorders &
Hyperventilation
 Patients have normal cardiopulmonary function of
intense dyspnea & suffocation
 May coincide w/ symptoms, such as chest pain,
anxiety, palpitation & paresthesia
 Anxiety often accompanied by breathlessness &
hyperventilation
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A patient with congestive heart failure, complains
that when he assumes a reclining position he
begins to feel dyspneic, what kind of condition is
this patient describing?
A.
B.
C.
D.
Platypnea
Orthopnea
Apnea
Eupnea
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Cardiopulmonary Symptoms (cont.)
 Cough
 Cough occurs when cough receptors in airways
are stimulated by inflammation, mucus, foreign
material, or noxious gases
 Weak cough is often due to high Raw, poor lung
recoil, weak muscles or pain
 Patients with airways disease often have loose,
productive cough
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All of the following are common causes of a weak
cough effort, except:
A.
B.
C.
D.
steroid administration
high airway resistance (Raw)
weak respiratory muscles
poor lung recoil
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Cardiopulmonary Symptoms (cont.)
 Sputum production
 Mucus from tracheobronchial tree not
contaminated by oral secretion is called “phlegm”
 Mucus from lower airways but is expectorated
through mouth is called “sputum”
 Sputum having pus cells is said to be “purulent”
 Foul smelling sputum is “fetid”
 Recent changes in sputum color, viscosity, or
quantity may indicate infection
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Cardiopulmonary Symptoms (cont.)

Hemoptysis


Coughing up blood or bloody sputum
Characterized—massive or non-massive
• Massive



More than 300 ml of blood expectorated over 24 hours
Common causes: bronchiectasis, lung abscess, & acute or
old tuberculosis
Distinguished from hematemesis (vomiting blood from
gastrointestinal tract)
• Non-massive

Common causes include: infection of airway, tuberculosis,
trauma, & pulmonary embolism
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Cardiopulmonary Symptoms (cont.)
 Chest pain
 Pleuritic chest pain—located laterally or posteriorly
- sharp in nature, & increases w/ deep breathing
(pneumonia & pulmonary embolism)
 Nonpleuritic chest pain—located in center of chest
& may radiate to shoulder or arm—often caused
by coronary artery disease & known as angina in
such cases (other causes: gastroesophageal
reflux & esophageal spasm)
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Cardiopulmonary Symptoms (cont.)
 Fever
 Elevation of body temperature due to disease
 May occur w/ simple viral infection of upper airway
or with serious bacterial pneumonia, tuberculosis,
& some cancers
 Causes increased metabolic rate, oxygen
consumption & carbon dioxide production
 Particularly dangerous in patients w/ severe
chronic cardiopulmonary disease, as it may cause
acute respiratory failure
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Cardiopulmonary Symptoms (cont.)
 Pedal edema


Swelling of lower extremities - most often due to
heart failure
2 subtypes;
1. Pitting edema—indentation mark left on skin after
applied pressure
2. Weeping edema—small fluid leak occurs at point
where pressure applied

Patients w/ chronic hypoxemic lung disease
usually develop right heart failure (cor pulmonale)
due to pulmonary hypertension
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Pleuritic chest pain can be associated with all
these diseases, except:
A.
B.
C.
D.
Pneumonia
Pulmonary Embolism
Costochondritis
Pneumothorax
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Medical History


Familiarizes clinician w/ patient’s condition
Reviewing patient’s chart:

Chief complaint (CC)/ history of present illness
(HPI)—explains current medical condition
 Past medical history (PMI)
 Review of systems (ROS)
 Social/Environmental history
 Advance directive
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Medical History (cont.)

RT’s priority—ensure all respiratory care
procedures are supported by physician order
(current, clearly written & complete)
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65 year-old female states that she has been
smoking for 40 years and approximately 1/2 pack
of cigarette per day. How would you document this
patient’s smoking history for the record?
A.
B.
C.
D.
10 pack-year
20 pack-year
30 pack-year
40 pack-year
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Physical Examination


Essential for evaluating patient’s problem &
determining ongoing effects of therapy
Consists of 4 steps:
1.
2.
3.
4.
Inspection (visually examining)
Palpation (touching)
Percussion (tapping)
Auscultation (listening with stethoscope)
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General Appearance


Done during first few seconds of patient
encounter
Indicators to assess:

Level of consciousness
 Facial expression
 Level of anxiety or distress
 Body positioning
 Personal hygiene
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Level of Consciousness

Sensorium: Level of consciousness &
orientation to time, place, person & situation
(oriented x 4)

Reflects oxygenation status of brain

Affected by poor cerebral blood flow
(hypotension)

If patient not alert—standard rating scale is
used to objectively describe patient’s level of
consciousness (Box 15-5, p. 338)
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Vital Signs (VS)



Easy to obtain & provide useful information
about current health status
VS provide first clue to adverse reactions to
treatment
Vital Signs = RR, HR, BT, BP
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Vital Signs (VS)
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Body Temperature





Normal: 98.6 oF or 37.0 oC
Increased temperature: Hyperthermia or
hyperpyrexia (fever)
Decreased temperature: Hypothermia
Can be measured at: mouth, axilla, ear or
rectum
Rectal temp: closest to core body
temperature
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A patient presents to the ER complaining of chills
and profuse sweating for the last two days. A rectal
temperature shows 102.3oF. This patient is said to
be:
A.
B.
C.
D.
Hypothermic
Febrile
Confused
Emaciated
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Heart Rate (HR)





Evaluate rate, rhythm & strength
Tachycardia: HR>100 beats/min.Treat
causes first
Bradycardia: HR<60 beats/min
Measure for full minute if pulse is irregular
Pulsus paradoxus vs. pulsus alternans
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Respiratory Rate (RR)




Resting adult RR is 12 to 18 breaths per
minute (bpm)
Tachypnea >20 bpm
Bradypnea <10 bpm
Do not reveal assessment of RR to patient
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Blood Pressure (BP)





Systolic: 90 to 140 mmHg
Diastolic: 60 to 90 mmHg
Pulse pressure: difference between systolic &
diastolic. Usually 30 to 40 mmHg
Hypertension: BP persistently >140/90
Hypotension: Systolic BP <90 mmHg or mean
art. pressure <65 mmHg
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Head & Neck Exam
 Head
 Abnormal signs help indicate respiratory problems
 Nasal flaring: often seen in infants w/ respiratory
distress—increased WOB
 Cyanosis of oral mucosa (central cyanosis)
indicates respiratory failure due to low oxygen
levels
 Pursed-lip breathing—seen in patients w/ COPD
to prevent collapse of small airways
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Head & Neck Exam (cont.)
 Neck
 Trachea should be midline;may shift away from
midline in certain thoracic disorders
 Jugular venous distention (JVD) is seen in
patients w/ CHF & cor pulmonale
 Enlarged lymph nodes in neck may occur w/
infection or malignancy
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A COPD patient arrives in the ER complaining of
swollen ankles and shortness of breath while
laying flat. On physical exam a positive JVD is
noted. You should suspect all of the following,
except:
A.
B.
C.
D.
right heart failure
cardiac tamponade
cor pulmonale
pulmonary hypertension
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Examination of Thorax

Barrel chest—seen w/ emphysema; indicates
poor lung recoil
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Examination of Thorax (cont.)



Pectus carinatum—abnormal protrusion of
sternum
Pectus excavatum—abnormal depression of
sternum
Kyphoscoliosis—abnormal curvature of spine;
often causes severe restrictive lung disease
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Examination of Thorax (cont.)
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Breathing Pattern

Abnormal breathing pattern—broken into 2
broad categories:
1.
2.

Associated w/ thoracic or pulmonary disease that
increases WOB (asthma)
Associated w/ neurologic disease (central sleep
apnea)
Rapid & shallow breathing is consistent w/
restrictive lung diseases
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Breathing Pattern (cont.)



Prolonged expiratory time—consistent w/
obstructive lung disease
Upper airway obstruction often causes
prolonged inspiratory time
Deep & fast breathing is consistent with
Kussmaul breathing (ketoacidosis)
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Diaphragmatic Fatigue


Found in many types of chronic & acute
pulmonary diseases
Signs of acute fatigue:

Tachypnea
 Diaphragm & rib cage muscles take turns
powering breathing (respiratory alternans)
 Abdominal paradox occurs w/ complete
diaphragmatic fatigue
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All of these are common causes of an abnormal
breathing pattern associated with thoracic or
pulmonary disease that increases work of
breathing, except:
A.
B.
C.
D.
Central sleep apnea
COPD
Asthma
Pulmonary edema
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Chest Palpation





Vocal & tactile fremitus is increased w/
pneumonia & atelectasis (consolidation)
Vocal & tactile fremitus is reduced w/
emphysema, pneumothorax, & pleural
effusion
Bilateral reduction in chest expansion—seen
in neuromuscular disorders & COPD
Unilateral reduction in chest expansion:
consistent w/ pneumonia or pneumothorax
Air leaks into subcutaneous tissues causes
“crepitus”—sign of subcutaneous emphysema
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Chest Percussion




Resonance of chest evaluated w/ percussion
Findings should be labeled as “normal,”
“increased,” or “decreased” resonance
Decreased resonance—pneumonia or pleural
effusion (consolidation)
Increased resonance—emphysema or
pneumothorax (air)
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Chest Auscultation

Lung sounds come in 2 varieties
1.
2.


Breath sounds
Adventitious lung sounds
Breath sounds = normal sounds of breathing
Adventitious lung sounds = abnormal sounds
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Breathing Pattern
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Chest Percussion
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Chest Auscultation (cont.)
 Breath sounds
 Tracheal breath sounds: heard directly over
trachea; created by turbulent flow; loud with
expiratory component equal to or slightly longer
than inspiratory component
 Bronchovesicular breath sounds: heard around
sternum; softer & slightly lower in pitch
 Vesicular breath sounds: heard over lung
parenchyma; very soft & low-pitched
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Chest Auscultation (cont.)
 Breath sounds
 Reduced w/ shallow breathing; when attenuation
is increased (when lung is hyperinflated—
emphysema)
 Increased when attenuation is reduced & turbulent
flow sounds pass through lung faster (pneumonia)
 Increased breath sounds often called “bronchial”
breath sounds
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Chest Auscultation (cont.)


Adventitious lung sounds
2 varieties:
1.
2.
Discontinuous
• Intermittent crackling
• Bubbling sounds of short duration
• Referred to as “crackles”
Continuous
• Referred to as “wheezes”
• Heard over the upper airway is called “stridor”
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Chest Auscultation (cont.)

Bronchial breath sounds



Abnormal if heard over peripheral lung regions
Replacing normal vesicular sounds when lung
tissue density increases
Diminished breath sounds

Occur when sound intensity at site of generation
(larger airways) is reduced due to shallow or slow
breathing, or
 When sound transmission through lung or chest
wall is decreased (COPD or asthma)
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Chest Auscultation (cont.)

Wheezes are



Consistent w/ airway obstruction
Monophonic wheezing indicates one airway is
affected
Polyphonic wheezing indicates many airways are
involved
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Chest Auscultation (cont.)

Stridor





Upper airway compromised
Chronic stridor—laryngomalacia
Acute stridor—croup
Inspiratory stridor—narrowing above glottis
Expiratory stridor—narrowing of lower trachea
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Chest Auscultation (cont.)

Coarse crackles



Airflow moves secretions or fluid in airways
Usually clears when patient coughs or upper
airway is suctioned
Fine crackles


Sudden opening of small airways in lung deep
breathing
Heard w/ pulmonary fibrosis & atelectasis
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Chest Auscultation (cont.)
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What condition may cause an RT to hear sudden
high-pitched popping noises during the lateinspiration phase?
A.
B.
C.
D.
Atelectasis
Asthma
Croup
Bronchitis
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Cardiac Examination



Chest wall overlying heart is known as
precordium
Inspected, palpated, & auscultated for
abnormalities
Right ventricular hypertrophy causes an
abnormal pulsation can be seen & felt near
lower margin of sternum; consistent w/ cor
pulmonale (COPD)
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Cardiac Examination (cont.)




Heave is abnormal pulsation felt over
precordium
Murmur is abnormal heart sound, often heard
over precordium
Murmurs produced by blood flowing through
narrowed opening
Systolic murmurs caused by stenotic
semilunar valves & incompetent AV valves
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Cardiac Examination (cont.)



Diastolic murmurs caused by stenotic AV
valves or incompetent semilunar valves
Murmurs may also be created by rapid blood
flow through normal valve in healthy people
during heavy exercise
Murmurs in babies may suggest
cardiovascular abnormalities related to
inadequate adjustment to extrauterine life
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Cardiac Examination (cont.)





S1: created by closure of AV valves
S2: created by closure of semilunar valves
S3: abnormal in adults & caused by rapid
filling of stiff left ventricle
S4: caused by atrial “kick” of blood into
noncompliant left ventricle
When patient has both S3 & S4—gallop
rhythm is present
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Abdominal Exam



Abdomen inspected & palpated for distention
tenderness
Abdominal compartment syndrome – when
intra-abdominal pressures >20mmHg.
An enlarged liver (hepatomegaly) is
consistent with cor pulmonale.
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Examination of Extremities

Digital clubbing (not common) - seen in large
variety of chronic conditions: congenital heart
disease, bronchiectasis, various cancers, &
interstitial lung diseases
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Examination of Extremities (cont.)


Digital cyanosis (acrocyanosis): often sign of
poor perfusion; hands& feet typically cool to
touch in such cases
Acrocyanosis occurs frequently in newborns;
usually disappears w/in 24 to 72 hrs after
birth
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