RET 1024 Introduction to Respiratory Therapy Module 4.2 Bedside Assessment of the Patient Inspection

Bedside Assessment of the Patient Systematic Examination Thorax and Lungs The physical examination of the chest and lungs should be performed in a systematic and orderly fashion – the most common sequence is as follows: Inspection Palpation Percussion Auscultation

Bedside Assessment of the Patient Systematic Examination Thorax and Lungs Topographic landmarks of the lung and chest

Bedside Assessment of the Patient Systematic Examination Thorax and Lungs Topographic landmarks of the lung and chest

Bedside Assessment of the Patient Systematic Examination Thorax and Lungs Topographic landmarks of the lung and chest

Bedside Assessment of the Patient Systematic Examination Thorax and Lungs Topographic landmarks of the lung and chest

Bedside Assessment of the Patient Systematic Examination Thorax and Lungs Topographic landmarks of the lung and chest

Bedside Assessment of the Patient Systematic Examination Thorax and Lungs Topographic landmarks of the lung and chest Left oblique fissure Left upper lobe Left lower lobe

Bedside Assessment of the Patient Systematic Examination Thorax and Lungs Topographic landmarks of the lung and chest

Bedside Assessment of the Patient Inspection Dyspnea Abnormal ventilatory pattern Use of accessory muscles of inspiration Pursed-lip breathing Substernal or intercostal retractions Nasal flaring Splinting due to chest pain

Bedside Assessment of the Patient Inspection Abnormal extremity findings: Altered skin color Digital clubbing Pedal edema Capillary refill Distended neck veins Tracheal deviation Cough (note characteristics) Sputum production Hemoptysis

Bedside Assessment of the Patient Dyspnea; shortness of breath as defined by the patient Patient’s sense that their work of breathing is excessive for their level of activity Shortness of breath becomes a concern when the drive to breathe is excessive or when the work of breathing increases

Bedside Assessment of the Patient Dyspnea Drive to breathe is excessive Hypoxemia Acidosis Fever Exercise Anxiety

Bedside Assessment of the Patient Dyspnea Increased work of breathing Narrowed airways, e.g., Asthma Bronchitis Lung become difficult to expand, e.g., Pneumonia Pulmonary edema Chest wall abnormality

Bedside Assessment of the Patient Dyspnea Positional Reclining – Orthopnea CHF Bilateral diaphragmatic paralysis Upright - Platypnea

Bedside Assessment of the Patient Dyspnea Patient’s description of their dyspnea “My chest is tight” “My breathing is too fast” “I feel like I’m suffocating”

Bedside Assessment of the Patient Inspection Abnormal Ventilatory Pattern Provide reliable clues about underlying pulmonary problem Rapid shallow breathing (Rate with a VT ) Caused by  lung volume and/or  lung compliance (CL) Atelectasis Pneumonia Pulmonary edema Pleural effusion Pneumothorax Adult respiratory distress syndrome (ARDS)

Bedside Assessment of the Patient Inspection Abnormal Ventilatory Pattern Prolonged exhalation time ( Rate with a  VT ) Caused by  airway resistance (Raw) Cystic fibrosis Brochiectasis Asthma Bronchitis Emphysema

Bedside Assessment of the Patient Inspection Abnormal Ventilatory Pattern Prolonged inspiratory time Upper airway obstruction – extrathoracic Epiglotitis Croup Extrathoracic tumor

Bedside Assessment of the Patient Inspection Use of accessory muscles During the advanced stages of chronic obstructive pulmonary disease (COPD), the accessory muscles of inspiration are activated when the diaphragm becomes significantly depressed by the increased residual volume (RV) and functional residual capacity (FRC) Accessory muscles of inspiration Scalene Sternocleidomastoid Pectoralis major Trapezius

Bedside Assessment of the Patient Inspection Use of accessory muscles Accessory muscles of expiration Recruited when airway resistance becomes significantly elevated Rectus abdominis External obliques Internal obliques Transversus abdominis

Bedside Assessment of the Patient Inspection Use of accessory muscles

Bedside Assessment of the Patient Inspection Pursed-lip Breathing Occurs in patients during the advanced stages of obstructive pulmonary disease Patient exhales through lips that are held in position similar to that used for whistling or blowing trough a flute Retarding the airflow through the pursed lips provides the airway with some stability - offsets early airway collapse

Bedside Assessment of the Patient Inspection Pursed-lip Breathing

Bedside Assessment of the Patient Inspection Retractions Caused by a greater than normal negative intrapleural pressure during inspiratory efforts to overcome low lung compliance as seen in patients with severe restrictive lung disorders, e.g., pneumonia, ARDS, and in premature newborns with surfactant deficiencies or idiopathic respiratory distress (IRDS) Sternal Intercostal Supraclavicular Subcostal

Bedside Assessment of the Patient Inspection Retractions Supraclavicular retractions Sternal retractions Intercostal retractions Subcostal retractions

Bedside Assessment of the Patient Inspection Nasal Flaring Often seen during inspiration in infants experiencing respiratory distress Provides a larger orifice for gas to enter the lungs during inspiration

Bedside Assessment of the Patient Inspection Splinting Due to Chest Pain Pleuritic Chest Pain Sudden sharp, stabbing type pain located laterally or posteriorly Worsens with deep breath Origin may be from: Chest wall Muscles Ribs Diaphragm Mediastinal structures Intercostal nerves Parietal pleura (pleurisy)

Bedside Assessment of the Patient Inspection Splinting Due to Chest Pain Pleuritic Chest Pain A characteristic feature of the following respiratory diseases: Pneumonia Pleural effusion Pneumothorax Pulmonary infarction Lung cancer Pneumoconiosis Fungal diseases TB

Bedside Assessment of the Patient Inspection Splinting Due to Chest Pain Nonpleuritic Chest Pain Described as constant “dull ache” or “pressure” located in the center of the anterior chest, may radiate to the shoulder Associated with the following disorders: Myocardial ischemia Pericardial inflammation Pulmonary hypertension Esophagitis Local trauma or inflammation of the chest cage, muscles, bones, or cartilage

Bedside Assessment of the Patient Inspection Abnormal Chest Configuration During inspection the respiratory care practitioner systematically observes the patient’s chest for both normal and abnormal findings Is the spine straight? Are any lesions or surgical scars evident? Are the scapulae symmetric?

Bedside Assessment of the Patient Inspection Abnormal Chest Configuration Anteroposterior (AP) diameter  Slightly with age and prematurely with COPD Barrel Chest – In the normal adult, the AP diameter of the chest is about half its lateral diameter (1:2). When the patient has barrel chest, the ration is (1:1) - associated with emphysema

Bedside Assessment of the Patient Inspection Abnormal Chest Configuration Pectus excavatum Pectus carinatum – funnel-shaped depression over the lower sternum (aka: “funnel chest”) -associated with restrictive lung defects – forward projection of the xiphoid process and lower sternum (aka: “pigeon breast”

Bedside Assessment of the Patient Inspection Abnormal Chest Configuration Kyphosis Scoliosis A “hunchbacked” appearance caused by curvature of the spine A lateral curvature of the spine that results in the chest protruding posteriorly and the anterior ribs flattening out

Bedside Assessment of the Patient Inspection Abnormal Chest Configuration Kyphoscoliosis The combination of kyphosis and scoliosis – may produce sever restrictive lung disease as a result of poor lung expansion

Bedside Assessment of the Patient Inspection Abnormal Chest Configuration Scars Lobectomy Pnemonectomy

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Altered Skin Color Digital Clubbing Pedal Edema Distended Neck Veins Tracheal Deviation

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Altered Skin Color A general observation of the patient’s skin color should be routinely performed Does the patient’s skin color look normal? Is the skin cold or clammy? Does the skin look ashen or pallid? Do the patient’s eyes , face, trunk, and arms have a yellow, jaundiced appearance Is there redness of the skin (erythema)? Does the patient appear cyanotic?

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Altered Skin Color Cyanosis – a blue-gray or purplish discoloration of the mucous membranes, fingertips, and toes Occurs when 5 g/dl of the hemoglobin is reduced (hemoglobin that is not bound with oxygen) Central Cyanosis Observed in the lips and oral mucosa of mouth - almost always a sign of hypoxemia

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Altered Skin Color Peripheral Cyanosis Easily seen in the fingernails Becomes visible when the amount of hemoglobin in the capillary blood exceeds 5-6 g/dL Mainly the result of poor blood flow, especially in the extremities Influenced by temperature Together with coolness of the extremities, peripheral cyanosis is a sign of poor perfusion

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Digital Clubbing Enlargement of terminal phalanges of the fingers and toes Significant manifestation of Cardiopulmonary disease Angle of the fingernail to the nail base increases, nail bed feel “spongy”

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Digital Clubbing Interstitial lung disease Bronchiectasis Various cancers (including lung cancer) Congenital heart problems that cause cyanosis Chronic liver disease Inflammatory bowel disease

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Pedal Edema Swelling of the lower extremities Commonly seen in patients with: Congestive Heart Failure (CHF) Cor pulmonale (right-sided heart failure) Liver disease Kidney disease

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Pedal Edema Firmly depress the skin for 5 seconds then release Normal – no indentation May see some pitting if person has been standing all day or is pregnant If pitting is present Subjective scale 1+ (mild, slight depression) 4+ (severe, deep depression)

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Capillary Refill Pressure is applied to the nail bed until it turns white, indicating that the blood has been forced from the tissue (blanching). Once the tissue has blanched, pressure is removed The health care provider will measure the time it takes for blood to return to the tissue, indicated by a pink color returning to the nail

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Capillary Refill Caused by reduced cardiac output and poor digital perfusion Blanch times that are >2 seconds may indicate one of the following: Dehydration Shock Peripheral vascular disease (PVD) Hypothermia

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Capillary Refill Normal refill Infant

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Capillary Refill Delayed refill Infant

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Distended Neck Veins In patients with cor pulmonale, severe flail chest, pneumothorax, or pleural effusion, the major veins of the chest that return blood to the right heart may be compressed. When this happens, venous return decreases and central venous pressure (CVP) increases. This condition is manifested by distended neck veins (also called jugular vein distention – JVD)

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Distended Neck Veins (JVD)

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Distended Neck Veins (JVD) Elevate head of patient’s bed to 45 Blood column should only be a few centimeters above the clavicle If venous pressure is elevated, neck veins may be distended as far as the jaw

Bedside Assessment of the Patient Inspection Abnormal Extremity Findings Tracheal Deviation Trachea normally in middle of neck Directly below the center of the suprasternal notch Shifts toward Collapsed lung Atelectasis Pneumonectomy Shifts away Increased air (tension pneumothorax) Increased fluid (pleural effusion Increased tissue (tumor)

Bedside Assessment of the Patient Tracheal Deviation Tracheal shift Pneumonectory

Bedside Assessment of the Patient Tracheal Deviation Tracheal shift Pleural effusion

Bedside Assessment of the Patient Inspection Cough Most common symptom in patients with pulmonary disease Occurs when cough receptors are stimulated Inflammation Mucus Foreign materials Noxious gases

Bedside Assessment of the Patient Inspection Cough Characteristics Dry or loose Productive or nonproductive Acute or chronic During day or night

Bedside Assessment of the Patient Dry, loose, productive … ?

Bedside Assessment of the Patient Inspection Sputum Production Airway disease may cause mucus production Phlegm – mucus from the tracheobronchial tree, not contaminated by oral secretions Sputum – mucus from the lung but passes through the mouth

Bedside Assessment of the Patient Inspection Sputum Production Terminology associated the sputum Purulent – sputum that contains pus (bacterial infection – thick, colored, sticky) Fetid – foul smelling sputum Mucoid – clear, thick sputum

Bedside Assessment of the Patient Inspection Sputum Production Recent changes in the color, viscosity, or quantity or sputum produced are often signs of infection and must be documented and reported to the physician

Bedside Assessment of the Patient Inspection Hemoptysis; coughing up blood or blood-streaked sputum from the lungs Massive - > 300 ml over 24 hours Bronchiectasis Lung abscess Acute or old tuberculosis Nonmassive - < 300 ml over 24 hours Infection of airways Lung cancer Tuberculosis Trauma Pulmonary embolism