Chapter 15 Bedside Assessment of the Patient Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982,...

Chapter 15

Bedside Assessment of the Patient

Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

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.

Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 2

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.

3Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

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.


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


Interviewing

Purposes Establish rapport with patient Obtain essential diagnostic information Help monitor changes in patient’s symptoms &

response to therapy



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 testsB.Helps select the best approach for therapyC.Helps monitor patient’s progress toward predefined goalsD.Determines how long the patient will remain in the hospital

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


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?


Cardiopulmonary Symptoms

DyspneaSensation of breathing discomfort by patient

(subjective feeling)Most important symptom RT is called upon to

assess & treat

BreathlessnessSensation of unpleasant urge to breatheCan be triggered by acute hypercapnia, acidosis &

hypoxemia



DyspneaSubjective experience. Should not be inferred from

observing patient`s breathing patternOrthopnea: dyspnea in reclining position;

associated w/ CHFPlatypnea: dyspnea in upright position associated

w/ arteriovenous malformationDegree of dyspnea is evaluated by asking about

level of exertion at which it occurs


Cardiopulmonary Symptoms (cont.)

Language of DyspneaAsk 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



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



Psychogenic Dyspnea: Panic Disorders & HyperventilationPatients have normal cardiopulmonary function of

intense dyspnea & suffocationMay coincide w/ symptoms, such as chest pain,

anxiety, palpitation & paresthesiaAnxiety often accompanied by breathlessness &

hyperventilation



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.Platypnea

B.Orthopnea

C.Apnea

D.Eupnea


CoughCough 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



All of the following are common causes of a weak cough effort, except:

A.steroid administration

B.high airway resistance (Raw)

C.weak respiratory muscles

D.poor lung recoil


Sputum productionMucus 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



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



Chest painPleuritic 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)



FeverElevation of body temperature due to diseaseMay 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



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



Pleuritic chest pain can be associated with all these diseases, except:

A.Pneumonia

B.Pulmonary Embolism

C.Costochondritis

D.Pneumothorax

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


Medical History (cont.)

RT’s priority—ensure all respiratory care procedures are supported by physician order (current, clearly written & complete)



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.10 pack-year

B.20 pack-year

C.30 pack-year

D.40 pack-year

Physical Examination

Essential for evaluating patient’s problem & determining ongoing effects of therapy

Consists of 4 steps:1. Inspection (visually examining)

2. Palpation (touching)

3. Percussion (tapping)

4. Auscultation (listening with stethoscope)


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


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)


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


Vital Signs (VS)


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



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.Hypothermic

B.Febrile

C.Confused

D.Emaciated

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


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


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


Head & Neck Exam

HeadAbnormal signs help indicate respiratory problemsNasal flaring: often seen in infants w/ respiratory

distress—increased WOBCyanosis 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


Head & Neck Exam (cont.)

NeckTrachea should be midline;may shift away from

midline in certain thoracic disordersJugular venous distention (JVD) is seen in patients

w/ CHF & cor pulmonaleEnlarged lymph nodes in neck may occur w/

infection or malignancy



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.right heart failure

B.cardiac tamponade

C.cor pulmonale

D.pulmonary hypertension

Examination of Thorax

Barrel chest—seen w/ emphysema; indicates poor lung recoil


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


Examination of Thorax (cont.)


Breathing Pattern

Abnormal breathing pattern—broken into 2 broad categories:1. Associated w/ thoracic or pulmonary disease that

increases WOB (asthma)

2. Associated w/ neurologic disease (central sleep apnea)

Rapid & shallow breathing is consistent w/ restrictive lung diseases


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)


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



All of these are common causes of an abnormal breathing pattern associated with thoracic or pulmonary disease that increases work of breathing, except:

A.Central sleep apnea

B.COPD

C.Asthma

D.Pulmonary edema

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


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)


Chest Auscultation

Lung sounds come in 2 varieties1. Breath sounds

2. Adventitious lung sounds Breath sounds = normal sounds of breathing Adventitious lung sounds = abnormal sounds


Breathing Pattern


Chest Percussion


Chest Auscultation (cont.)

Breath soundsTracheal 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



Breath soundsReduced 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



Adventitious lung sounds 2 varieties:

1. Discontinuous• Intermittent crackling

• Bubbling sounds of short duration

• Referred to as “crackles”

2. Continuous• Referred to as “wheezes”

• Heard over the upper airway is called “stridor”



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)



Wheezes are Consistent w/ airway obstruction Monophonic wheezing indicates one airway is

affected Polyphonic wheezing indicates many airways are

involved



Stridor Upper airway compromised Chronic stridor—laryngomalacia Acute stridor—croup Inspiratory stridor—narrowing above glottis Expiratory stridor—narrowing of lower trachea



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



What condition may cause an RT to hear sudden high-pitched popping noises during the late-inspiration phase?

A.Atelectasis

B.Asthma

C.Croup

D.Bronchitis

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)


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



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



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


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.


Examination of Extremities

Digital clubbing (not common) - seen in large variety of chronic conditions: congenital heart disease, bronchiectasis, various cancers, & interstitial lung diseases


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


Chapter 15 Bedside Assessment of the Patient Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982,...

Documents

Transcript of Chapter 15 Bedside Assessment of the Patient Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982,...