1. Chapter 15 Bedside Assessment of the Patient

2. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 2 Objectives  Describe why patient interviews are necessary and the techniques useful for conducting an interview.  Identify the abnormalities in lung function associated with common pulmonary symptoms.  Identify the breathing patterns associated with underlying pulmonary pathologic conditions.

3. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 3 Objectives (cont.) Objectives (cont.)  Identify the terms used to describe normal and abnormal lung sounds.  Describe the mechanisms responsible for normal and abnormal lung sounds.  Describe why it is necessary to examine the precordium, abdomen, and extremities in the patient with cardiopulmonary disease and the common abnormalities seen in these locations.

4. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 4 Introduction  Bedside assessment is the process of interviewing and examining the patient for the signs and symptoms of disease.  It is inexpensive and of little risk to the patient.  It is done as part of the initial assessment to identify a diagnosis and in an ongoing manner to evaluate the effects of treatment.

5. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 5 Interviewing Purposes  To establish a rapport with patient  To obtain essential diagnostic information  To monitor changes in the patient’s symptoms over time and with treatment

6. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 6 Interviewing (cont.) Technique  Introduce yourself in the social space.  Interview in the personal space.  Use appropriate eye contact.  Assume a physical position at the same level with the patient.  Avoid the use of leading questions; use neutral questions.

7. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 7 Interviewing (cont.) Common questions to ask for each symptom  When did it start?  How severe is it?  Where on the body is it?  What seems to make it better or worse?  Has it occurred before?

8. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 8 Cardiopulmonary Symptoms Dyspnea  Occurs when the work of breathing is too high and/or when the drive to breathe is elevated  Orthopnea: dyspnea in the reclining position; associated with CHF  Platypnea: dyspnea when moved to the upright position  Degree of dyspnea is evaluated by asking about the level of exertion at which it occurs.

9. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 9 Cardiopulmonary Symptoms (cont.) Cough  Cough occurs when the cough receptors in the airways are stimulated by inflammation, mucus, foreign material, or noxious gases.  Weak cough is often due to high Raw, poor lung recoil, or weak muscles.  Patients with airways disease often have a loose, productive cough.

10. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 10 Cardiopulmonary Symptoms (cont.) Sputum production  Mucus that comes from the lower airways but is expectorated through the mouth is called “sputum.”  Sputum that has pus cells in it is said to be “purulent.”  Sputum that is foul smelling is “fetid.”  Recent changes in the color, viscosity, or quantity of sputum may indicate infection.

11. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 11 Cardiopulmonary Symptoms (cont.) Hemoptysis  Coughing up blood or bloody sputum from the airways  Most often occurs in patients with a history of lung disease  Common causes include bronchitis, lung cancer, tuberculosis, trauma, and pulmonary embolism.  Vomiting blood from the gastrointestinal tract is known as hematemasis.

12. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Cardiopulmonary Symptoms (cont.) Chest pain  Pleuritic chest pain is located laterally or posteriorly, is sharp in nature, and increases with deep breathing.  Nonpleuritic chest pain is located in the center of the chest and may radiate to the shoulder or arm; it is often caused by coronary artery disease and is known as angina in such cases.

13. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 13 Cardiopulmonary Symptoms (cont.) Fever  Defined as an elevation of body temperature due to disease  Most often due to viral infection; also seen with pneumonia, tuberculosis, and some cancers  Fever with a cough suggests respiratory infection.  Fever increases the body’s need for oxygen.

14. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 14 Cardiopulmonary Symptoms (cont.) Pedal edema  Swelling of the ankles is most often due to heart failure.  Patients with chronic hypoxemic lung disease usually develop right heart failure (cor pulmonale) due to pulmonary hypertension.  Pedal edema may indicate the need for oxygen therapy.

15. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 15 Physical Examination  Level of consciousness and orientation to time, place, and person reflect the oxygenation status of the brain.  The vital signs (VS) are easy to obtain and provide useful information about the current health status of the patient.  Vital Signs = RR, HR, BT, BP

16. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 16 Head and Neck Exam  Nasal flaring is often seen in infants with respiratory distress and an increase in the WOB.  Cyanosis of the oral mucosa indicates respiratory failure due to low oxygen levels.  Pursed-lip breathing is seen in patients with COPD who have obstruction of the small airways.

17. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 17 Head and Neck Exam (cont.)  The trachea should be midline; it may shift left or right with upper lobe abnormalities or mediastinal tumors.  Jugular venous distention is seen in patients with CHF and cor pulmonale.  Enlarged lymph nodes in the neck may occur with infection or malignancy.

18. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 18 Examination of the Thorax  A barrel chest is seen with emphysema and indicates that lung recoil is poor.

19. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 19 Examination of the Thorax (cont.)  Pectus carinatum  abnormal protrusion of the sternum  Pectus excavatum  abnormal depression of the sternum  Kyphoscoliosis  abnormal curvature of the spine; often causes severe restrictive lung disease

20. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 20 Breathing Pattern  Rapid and shallow breathing is consistent with restrictive lung diseases.  A prolonged expiratory time is consistent with obstructive lung disease.  Upper airway obstruction often causes a prolonged inspiratory time.  Deep and fast breathing is consistent with Kussmaul breathing (ketoacidosis).

21. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 21 Chest Palpation  Tactile fremitus is increased with pneumonia and atelectasis.  Tactile fremitus in reduced with emphysema, pneumothorax, and pleural effusion.  A unilateral reduction in chest expansion is consistent with pneumonia or pneumothorax.

22. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 22 Chest Percussion  Resonance of the chest is evaluated with percussion.  The findings should be labeled as “normal, ” “increased, ” or “decreased” resonance.  Decreased resonance  pneumonia or pleural effusion.  Increased resonance  emphysema or pneumothorax.

23. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 23 Chest Auscultation  Lung sounds come in two varieties: breath sounds and adventitious lung sounds.  Breath sounds = the normal sounds of breathing  ALS = the abnormal sounds superimposed on the breath sounds (crackles and wheezes)

24. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 24 Chest Auscultation (cont.) Breath sounds  Tracheal breath sounds: heard directly over the trachea and created by turbulent flow; loud and high- pitched  Bronchovesicular breath sounds  heard around the sternum; softer and slightly lower in pitch  Vesicular breath sounds  heard over lung parenchyma; represent attenuated turbulent flow sounds from the larger airways; very soft and low- pitched

25. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 25 Chest Auscultation (cont.) Breath sounds  Reduced with shallow breathing and when attenuation is increased (when the lung is hyperinflated as in emphysema)  Increased when attenuation is reduced and the turbulent flow sounds pass through the lung faster (pneumonia)  Increased breath sound are often called “bronchial” breath sounds.

26. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 26 Chest Auscultation (cont.) ALS  Come in two varieties: continuous and discontinuous  Continuous ALS are called “wheezes.”  A continuous ALS heard over the upper airway is called “stridor.”  Discontinuous ALS are called “crackles.”

27. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 27 Chest Auscultation (cont.)  Wheezes are consistent with airways obstruction; monophonic wheezing indicates one airway is affected, and polyphonic wheezing indicates many airways are involved.  Fine crackles are produced by the sudden opening of small airways in the lung with deep breathing; they are heard with pulmonary fibrosis and atelectasis.

28. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 28 Chest Auscultation (cont.)

29. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 29 Cardiac Examination  The chest wall overlying the heart is known as the precordium.  It is inspected, palpated, and auscultated for abnormalities.  Right ventricular hypertrophy causes an abnormal pulsation that can be seen and felt near the lower margin of the sternum; this is consistent with cor pulmonale.

30. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 30 Cardiac Examination (cont.)  A heave is an abnormal pulsation felt over the precordium.  A murmur is an abnormal heart sound most often heard over the precordium.  Murmurs are produced by blood flowing through a narrowed opening.  Systolic murmurs are caused by stenotic semilunar valves and incompetent AV valves.

31. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 31 Cardiac Examination (cont.)  Diastolic murmurs are caused by stenotic AV valves or incompetent semilunar valves.  Murmurs may also be created by rapid blood flow through a normal valve in healthy people during heavy exercise.  Murmurs in babies may suggest cardiovascular abnormalities related to inadequate adjustment to extrauterine life.

32. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 32 Cardiac Examination (cont.)  S1 is created by closure of the AV valves.  S2 is created by closure of the semilunar valves.  An S3 is abnormal in adults and caused by rapid filling of a stiff left ventricle.  An S4 is caused by an atrial “kick” of blood into a noncompliant left ventricle.  When a patient has both an S3 and an S4, a gallop rhythm is present.

33. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 33 Abdominal Exam  The abdomen is inspected and palpated for distention and tenderness.  An enlarged liver (hepatomegaly) is consistent with cor pulmonale.  Abdominal paradox is present when the abdomen sinks inward during inspiration; this is a sign of diaphragm fatigue.

34. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 34 Examination of the Extremities  Digital clubbing is not common but is seen in a large variety of chronic conditions: congenital heart disease, bronchiectasis, various cancers, and interstitial lung diseases.

35. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 35 Examination of the Extremities (cont.)  Digital cyanosis is often a sign of poor perfusion; the hands and feet are typically cool to the touch in such cases.