Bedside Assessment - Respiratory Therapy Files
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Transcript Bedside Assessment - Respiratory Therapy Files
Fundamentals of the
Chest Physical Exam
RESD 60
Bedside Assessment Skills
Patient Interview
History Taking
Physical Examination
Medical Record
Keeping
Respiratory Recap
Variables
supporting a therapeutic climate
Caring Demeanor
Competence
Eye Contact
Judicious use of touch
Professional Image
Terms used to describe illness
Symptom
Sign
Finding
Syndrome
Disease
Symptom
Something
felt by an individual as a
departure from normal.
A
subjective abnormality perceived by the
patient.
Examples:
dyspnea
chest pain
leg swelling
Sign
An
observable or measurable bodily
manifestation that serves to indicate the
presence of malfunction or disease.
Examples:
tachypnea
dullness to percussion
pedal edema
Sign or symptom
In
the investigation of a symptom or sign
be quantitative whenever possible.
“8 on a scale of 10”
“2 to 3 minutes”
Finding
An observation or manifestation of disease as a
result of an investigative procedure.
Typical procedures; blood work, radiology.
Examples:
right lower lobe infiltrate
increase white blood cell count.
Syndrome
A
set of symptoms, signs, and/or findings
that characteristically occur together which
may signify a specific disease process.
Examples
COPD
pneumonia
Disease
A
particular pathologic condition or
process whose pathophysiology or cause
is known.
Examples
pneumococcal pneumonia
alpha-1-antitrypsin deficiency
Cardinal signs and symptoms of Cardiopulmonary
Disease
Dyspnea
Cough
Hemoptysis
Chest
Pain
Cardinal signs and symptoms of
Cardiopulmonary Disease
Wheezing
Clubbing
Stridor
Edema
Cyanosis
Dyspnea
Shortness
of breath
The
subjective sensation that one’s
breathing is inadequate or insufficient.
An
uncomfortable awareness of the act of
breathing.
Cough
A sudden, noisy expulsion of air from the lungs,
brought about through a reflex action, for the
purpose of clearing the airways.
A normal event that becomes a symptom when it
is frequent or bothersome.
Nonproductive or productive
Hemoptysis
The
coughing up of blood from the
respiratory tract below the level of the
larynx.
This
term is usually reserved for fresh
blood.
Chest Pain
Any
uncomfortable sensation referable by
the patient to the thoracic area.
Pleuritic
- worsened by breathing or
coughing.
Wheezing
A
high-pitched, musical sound produced
when the patient breathes, originating in
narrowed airways.
May
occupy either a portion or all of the
respiratory cycle.
Stridor
A
harsh, high-pitched sound, usually on
inspiration.
Associated
with partial laryngeal
obstruction.
Cyanosis
A
bluish discoloration of the skin and
mucous membranes due to the presence
of increased quantities of reduced
hemoglobin.
Cyanosis
may be peripheral or central.
Cyanosis
Clubbing
Enlargement of the
end of the fingers and
toes due to buildup of
soft tissue in the nail
bed.
Occurs in several
chronic lung
diseases.
Clubbing of the fingers
Edema
Presence
of large amts of fluid in the
intercellular tissue spaces of the body.
Pitting
- seen with CHF. Increased fluid
due to increased hydrostatic pressure.
Non-pitting
- seen with infection due to
increased capillary permeability.
Pitting Edema
Present Illness
The
present illness is the clinical
problem of primary concern at the
moment.
The
chief complaint is what caused
the patient to seek medical attention.
Physical Examination
A
physical examination is done to detect
the the physical signs of disease.
The
RCP has 3 considerations:
Diagnostic
Therapeutic
Evaluation
Components of Physical Examination
Inspection
Palpation
Percussion
Auscultation
Inspection
View
from the door
Isolation
patient position
Family
equipment
Entering the room
Introduction
Patient’s
last name
Establish
a brief
rapport
Vital Signs
body temperature
heart rate
respiratory rate
blood pressure
Sensorium
An
alert patient is oriented to person,
place and time.
An
abnormal sensorium suggests that a
person may have poor oxygenation.
Can
also occur with drugs and disease
states.
Physical Inspection - Head to
Toe
Head
facial expression
color
nose
mouth
eyes
Physical Inspection
Neck
Tracheal position
Jugular venous pressure
Accessory muscle use
Trachea
Tracheal Deviation to the R
Jugular Venous Pressure
JVD
Chest configuration
The
normal adult thorax is
broader for side to side than front
to back.
An
increased anteroposterior (AP)
diameter is common with
emphysema. Barrel chest.
Chest configuration
Pectus
excavatum - funnel shaped
depression of the lower portion of the
sternum.
Pectus
carinatum - sternum protrudes
outward.
Sternal Abnormalities
Increased A-P Diameter
Physical examination - spinal
column.
Scoliosis
- abnormal, lateral curvature of
the spine.
Kyphosis
- an increased AP curvature of
the spine.
Kyphoscoliosis
- combination
Kyphosis
Physical examination breathing pattern
Respiratory
rate and pattern are always
evaluated.
Rapid
and shallow breathing is associated
with restrictive lung disease.
Prolonged
expiratory time is common with
obstructive disease.
Physical Examination breathing pattern
Note
the timing of the inspiratory and
expiratory phase of breathing.
A
prolonged expiratory time is common
with obstruction of the intrathoracic
airways.
Obstruction
of the upper airway leads to
prolonged inspiratory time.
Breathing pattern
Assess
Look
the patient’s effort to breathe.
for:
retractions
paradoxical respirations
flail chest
chest symmetry
Pursed lips
Tripoding
Pursed Lips
Tripod and Pursed Lips
Physical examination - digits
The
digits are inspected for:
cyanosis
clubbing
Palpation
Palpation
is used to evaluate the
symmetry and degree of chest expansion
with breathing.
Tactile
Fremitus
Capillary
Refill
Tracheal
position
To palpate, percuss and auscultate
chest you must know the anatomy.
Posterior View
Palpating for Lung Expansion
Percussion
Percussion
is performed to help evaluate
relative amounts of air and solid material
in the underlying lung.
Percussion
over normal air-filled lung will
produce a drum like sound described as
normal resonance.
Percussion
Increased
or hyper resonance is a ,
lower pitched sound.
This
occurs with emphysema or
pneumothorax.
Percussion
Dull
or flat describes a note that is
softer and higher-pitched than
normal.
This
sound is heard over areas of
pneumonia, atelectasis, lung tumor,
or pleural effusion.
Tactile Fremitus
Auscultation
Auscultation
is the process of listening to
sounds produced within the body with a
stethoscope.
Whenever
possible the patient should be
sitting upright.
Stethoscope
Anterior Auscultation
Lateral Auscultation
Posterior Auscultation
Auscultation
Inspiration
and expiration should be
evaluated for length and adventitious
sounds.
Auscultate
directly on the skin when
possible.
Auscultate
anterior, lateral, and posterior
chest wall surfaces.
Normal Breath Sounds
Normal
breath sounds are divided into
three different types
Bronchial
Bronchovesicular
Vesicular
Bronchial breath sounds
Loud
and high-pitched
equal
inspiratory and expiratory
heard
over trachea
also
called tracheal, tracheobronchial or
tubular
Bronchovesicular breath sounds
Softer
and lower pitched than bronchial
breath sounds.
Heard
on the anterior chest near the
mainstem bronchi in the first and second
intercostal spaces.
Heard
on the posterior chest between the
scapulae.
Vesicular breath sounds
Soft,
low-pitched sounds, heard during
auscultation over the lung.
Normal
air-filled lung contains millions of
alveoli, which act as a sound filter to
turbulent flow in the central airways.
Vesicular breath sounds
Flow
in the peripheral airways is laminar
and does not contribute significantly to
sound production.
If
the vesicular breath sound is softer than
expected, it is describes as diminished,
decreased, or even absent.
Vesicular breath sounds
Breath
sounds are decreased with the
following:
shallow breathing
hyperinflation
obstructed airways
pleural effusion
pneumothorax
obesity
Vesicular breath sounds
Louder
than expected vesicular breath
sounds are described as harsh.
Consolidation
does not filter sound, but
allows them to pass through the lung more
directly.
Adventitious breath sounds
Abnormal
sounds heard during
auscultation are termed adventitious
breath sounds.
The
can be continuous, musical sounds or
discontinuous, non-musical.
Continuous/musical
Wheeze
- low pitched sound resulting from
narrowing of the airways.
Timing
is usually expiratory, but can be
inspiratory or both.
“louder”
wheezes usually mean moderate
obstruction.
Continuous/musical
Low
pitched continuous sounds are
termed rhonchi.
Timing
is usually expiratory.
Indicative
of secretions in the lung.
Continuous/musical
A
high-pitched continuous sound heard
over the upper airway is referred to as
stridor.
Stridor
is often audible and can be a sign
of a life-threatening disorder.
Discontinuous Sounds
Sounds
described as intermittent,
crackling, bubbling, and of short duration.
Termed
rales or crackles.
Crackles
Produced
by two mechanisms;
excessive airway secretions with breathing
and sudden opening of the small airways.
Sudden opening of the small airways.
Crackles
Crackles
are inspiratory sounds and
associated with restrictive disorders such
as:
atelectasis (late inspiratory)
pneumonia
pulmonary fibrosis
Voice Sounds
Normally,
air-filled lung filters the voice so
that it is heard as low-pitched mumble
over the chest wall.
When
lung tissue becomes dense, vocal
resonance increases and the voice is
heard more clearly.
Voice Sounds
Increase
in vocal resonance is termed
bronchophony.
An
increase in vocal resonance is heard
with the consolidation that occurs with
pneumonia.
Voice Sounds
A
decrease in vocal resonance occurs
when the lung becomes less dense, as
with hyperinflation.
Voice Sounds
When
to voice sound increases in intensity
and takes on a nasal or bleating
characteristic, it is termed egophony.
Ask
the patient to say “e” and the “e” will
be heard as “a” over the area of
consolidation.
Voice Sounds
When
consolidation is present, whispered
sounds are transmitted more directly.
When
whispered sounds are heard with
more clarity, they are described as
whispered pectoriloquy.
Neurological Assessment
LOC
– Level of Consciousness
Glasgow comma scale
PERRLA—pupils equal, round, and
reactive to light and
accommodation
Neurologic Assessment
Posturing
Decerebrate
Decorticate