1. Lecture Notes
Chapter 1: Introduction to Patient Assessment

2. Objectives  Define the role of the respiratory therapist in
patient assessment
List the most common symptoms associated with cardiopulmonary disease and the common causes of each
List common physical procedures performed to
evaluate patients with cardiopulmonary disease
and the implications of abnormalities
Explain the laboratory tests done to evaluate
patients with diseases of the chest and common
causes of abnormalities   

3. Introduction  Patient assessment is a vital part of patient care in
any setting
Emergency department Intensive care unit (ICU) Home-care setting
 Clinicians best at patient assessment are those
who are rigorous in their daily patient care

4. Medical History and Interview
 Gathers important information about what is
wrong with the patient
 Allows rapport to be established
 Requires clinician’s knowledge about diseases
 Ask appropriate questions

5. Medical History and Interview  Basic questions 
When did the problem start?
Have you ever had this problem before?
How severe is the problem?
Has the severity changed since onset? What aggravates or relieves the problem? What region of the body is affected? 
Answers to these questions will help determine
a differential
diagnosis, what further tests may be needed, and what initial therapy
may be appropriate.

6. Medical History and Interview 
Symptoms: Shortness of Breath (Dyspnea) 
Common symptom in cardiopulmonary disease 
Usually worsens with exertion and improves with rest. 
Dyspnea at rest indicates poor cardiopulmonary reserve
May worsen with position
 Orthopnea: reclining (supine) – heart failure
 Platypnea: upright – post lung surgery 
Dyspnea occurring with change in position is abnormal.
Any pathologic lung change that increases the work of breathing usually will lead to dyspnea, especially during exertion.

7. Medical History and Interview  Symptoms: Cough 
One of the most common symptoms of cardiopulmonary
disease
Cough receptors of large airways are stimulated: Mechanical(occurs when foreign bodies touch the airway chemical (irritating gas), inflammatory, thermal (cold air).
Common causes 
wall.),  
Acute respiratory infections
Asthma
Gastroesophageal reflux
Post-nasal drip 
Identify severity, frequency, associated sputum production 
weak cough may indicate thoracic or abdominal pain or
neuromuscular disease.

8. Medical History and Interview  Symptoms: Sputum Production 
Mucus is normally produced in small amounts in the airways,
defense against invasion by germs. It is moved to the larynx by cilia. It is not normally noticed by healthy people. Sign of
disease of the airways or lungs 
Most common cause: cigarette smoking
 Other causes: inflammation – asthma/pneumonia
Quality  
Mucoid = airway disease without infection (clear and thick)
Fetid = infection by anaerobes (foul Smelling)
Purulent = bacterial infection (contains pus, green or yellow)
Copious = bronchiectasis ( large amounts)

9. Medical History and Interview  Symptoms: Chest Pain 
Pleuritic chest pain 
Is made worse by breathing, coughing, sneezing, moving
chest wall
Sharp in nature 
Associated with pleuresy, pneumothorax,
embolism, pneumonia
pulmonary 
Nonpleuritic chest pain 
Located centrally in the chest
Usually not affected by respiratory efforts
It may radiate – shoulder, arm, jaw, back
Dull pressure
Associated with ischemic heart disease

10. Medical History and Interview  Symptoms: Hemoptysis 
Spitting up of blood from tracheobronchial
Etiology
tree 
Pneumonia
Trauma
Bronchitis/bronchiectasis
Bronchogenic carcinoma
Tuberculosis
Pulmonary embolism 
Massive hemoptysis = 200–600
mL/day

11. Medical History and Interview 
Symptoms: Fever increase in body temperature caused
disease by 
Most often a manifestation of infection
Increases O2 consumption and CO2 production
Common respiratory problems associated with fever 
Viral infections
Bacterial bronchitis, pneumonia
Fungal infections
Tuberculosis 
Immunocompromised patients may not generate fever
despite severe infection 
The degree of fever depends on the severity of the infection
the patient’s ability to respond to the infection.
and

12. Medical History and Interview  Symptoms: Wheeze 
Airway wall vibration between partially open and
closed position as air passes
speed
Common in
through at
high  
Asthma
Congestive heart failure
Bronchitis 
Usually associated with dyspnea 
Wheezing may be associated with cough, sputum,
and dyspnea when airway disease is present.

13. Physical Examination  To confirm or rule out suspected illness from
interview
 To identify abnormalities not even related to the
chief complaint
 RTs = to evaluate response to therapy

14. Physical Examination: Vital Signs (VS) and Sensorium
 VS provide an index of patient’s acute condition
 Heart rate
 Tachycardia = > 100 beats/min
 Anxiety, hypoxemia, heart failure, fever, bronchodilators
 Bradycardia = < 60 beats/min
 Hypothermia, SA node damage, vagal stimulation

15. Physical Examination: (VS) and Sensorium Vital Signs
 Respiratory rate
 Tachypnea = > 20 breaths/min
 Pulmonary disease
 Pain, anxiety, fever, exertion
 Bradypnea = < 10 breaths/min
Vital
Signs
(not common)
 Hypothermia and CNS disorders

16. Physical Examination: (VS) and Sensorium Vital Signs
 Blood pressure (120/80)
Vital
Signs 
Hypotension = < 90/60 mm Hg
 Heart failure, vasodilatation, hypovolemia
 Puts patient at risk for shock
Hypertension = > 140/90 mm Hg
 Risk factor for heart failure and stroke
 Cause often unknown 

17. Physical Examination: (VS) and Sensorium Vital Signs
 Body temperature
Vital
Signs 
37°C +/- 0.5°C (98.6°F +/- 1°F)
Fever = infections
Hypothermia
 Head injury that damage the hypothalamus,
drowning, medications
Body temperature affects O2 consumption
near 

18. Physical Examination: Vital (VS) and Sensorium Signs
Sensorium assessment 
Patient’s level of consciousness (LOC)
Reflects 
Adequacy of cerebral blood flow
Adequacy of brain oxygenation
Net effect of acid–base balance
Electrolyte balance
Nutritional status
Integrity of other organ systems 
The patient who is alert and oriented as
to time, place,
3”. Confusion
and person is said to be “oriented times
patient is disoriented. Disoriented patient may indicate
respiratory failure

19. Physical Examination: Vital (VS) and Sensorium Signs
 Pulse oximetry “Fifth vital sign”
Signs 
Intermittent or continuous monitoring
oxygenation status of 
Reads amount of light absorption and
determines degree of oxygenation
Falsely high if HbCO present
Falsely low if poor perfusion 

20. Physical Examination: Chest Inspection
 Breathing pattern it can provide important clues
regarding the underlying lung pathology 
Prolonged expiratory phase
 Intrathoracic airway obstruction asthma, bronchitis.
Prolonged inspiratory phase 
 Extrathoracic airway obstruction
airway (epiglottitis)
Rapid and shallow breathing
 Restrictive lung disease
Abdominal paradox
narrowed upper  
 Diaphragmatic fatigue common in patients with acute exacerbations
of COPD.

21. Physical Examination: Chest Inspection
 Degree of symmetrical chest expansion
 Deformities 
Scoliosis – lateral curvature of spine
Kyphosis – A-P curvature of the spine
Kyphoscoliosis – both
Barrel chest – COPD
Pectus excavatum – sternal depression
Pectus carinatum – sternal protrusion

23. Physical Examination: Chest Palpation
Tactile fremitus patient is asked to repeat the phrase
“1-
2-3” or “99” while the examiner palpates the
comparing side to side.
chest
wall 
Increased in presence of lung densities
 Pneumonia
Decreased when lung is less dense
 Emphysema
Decreased if pleural space is occupied
 Pleural effusion, pneumothorax   
Presence of crepitation on the skin
 Subcutaneous emphysema

24. Physical Examination: Chest Percussion
 Tapping (chest percussion) to detect changes in lung density
 Normal resonant sound
 Decreased resonance (dull)
 Increased lung density or pleural effusion
 Increased resonance 
Decreased lung density
Pneumothorax
Pneumonia

25. Physical Examination: Auscultation Chest
 Information about
 Patency of the airway
 Condition of lung parenchyma
 Normal breath sounds
Chest 
Tracheal heard directly over
the trachea
Bronchovesicular heard around the sternum
on the anterior chest wall *** between the scapulae on the posterior chest wall.
Vesicular over the areas of the chest wall 

26. Physical Examination: Auscultation Chest
 Abnormal breath sounds
Chest 
Bronchial breath sounds
 Pneumonia, atelectasis, fibrosis
Diminished breath sounds  
Loss of lung parenchyma = emphysema
Diseases of the chest or pleural space
Shallow breathing

27. Physical Examination: Auscultation Chest
 Continuous adventitious breath
Chest
sounds 
Wheezing (intrathoracic) 
Musical quality
Expiratory
Polyphonic = high-pitched = asthma/CHF
Monophonic = low-pitched = single airway
obstruction 
Stridor (extrathoracic) 
Usually inspiratory

28. Physical Examination: Chest Auscultation
 Discontinuous adventitious breath sounds 
Crackles 
Sudden opening of small airways 
Fine crackles
Small airways
Late inspiration 
Movement of excessive
secretions
with breathing 
Coarse crackles
Large airways
Inspiration and expiration

29. Physical Examination: Examination of Other Parts of the Body
 Neck
 Jugular Venous Distention
degree angle
 Right ventricular failure
 Precordium
(JVD)
evaluated at 45 
Ventricular heave
 Ventricular hypertrophy
Normal heart sounds “lub-dub” (S1, S2) Gallops (S3, S4) in heart failure Murmurs valves stenosis 

30. Physical Examination: Examination of Other Parts of the Body
 Extremities
 Digital clubbing COPD
 Peripheral cyanosis
 Abdomen
 Distension
 Hepatomegaly
 Mouth ~
circulatory
failure
 Oral cyanosis ~ respiratory failure
 Pursed-lip breathing COPD to maintain patency airways during exhalation.
ofdistal

31. Interpretation of Lab Data: and Fluid Tests Blood
 Complete blood count (CBC)
Blood 
White blood cells (WBCs)
 Leukocytosis vs. leukopenia
Red blood cells (RBCs)
 Polycythemia vs. anemia
Hemoglobin (Hb)  

32. Interpretation of Lab Data: Blood and Fluid Tests
 Serum Electrolytes to evaluate the general health condition 
Sodium (Na+)
Potassium (K+) Chloride (Cl-) Bicarbonate (HCO3-)

33. Interpretation of and Fluid Tests Lab Data: Blood
 Microbiology section
 Gram stain
 Culture
 Cardiac enzymes
Lab
Data:
Blood 
Creatin phosphokynase
Troponin
(CPK)
(CPK) and troponin enzymes are usually
elevated within hours of a heart attack.

34. Interpretation of Blood Gases Lab Data: Arterial  Oxygenation 
 PaO2: 90–100 mm Hg
Lab Data: Arterial 
Acid–base 
pH: 7.35–7.45
Acidemia vs. alkalemia
 Hypoxemia:
mm Hg
 Ventilation
< 60 
Respiratory
metabolic
vs.
 PaCO2: 35–45 mm Hg
 Hypercapnia vs.
hypocapnia

35. Interpretation of Lab Data: Pulmonary Function Testing
Lung volumes
 VC the amount of gas fully exhaled after a maximum inhalation
 Restrictive (due to low lung volumes) vs. obstructive
(narrowed airways)
Airway patency
 FEV1forced expiratory volume in1 second
 FEF 25%–75% the middle half of the forced vital capacity.
These measures of flow help determine whether
obstructive lung disease is present.  

36. Interpretation of Radiographs: Chest Radiograph
 Identifies changes as disease changes lung density
 Identifies proper position of 
ETT: 3–5 cm above carina
Chest tube
Nasogastric tube
 Types of densities identified 
Bone
Water
Fat
Air
Radiopaque vs.
radiolucid

37. Interpretation of Radiographs: Chest Radiograph
 Radiopaque = increased density
 Pneumonia
 Tumors
 Radiolucid = decreased density
 Emphysema
 Pneumothorax
 Cardiac size
 Cardiomegaly

38. Interpretation of Clinical Chest Radiograph Lab Data:
 Computerized tomography
Lab
Data: 
More detail images
Cross-sectional view
Best for evaluation of tumors

39. Interpretation of Clinical Lab Data
 Electrocardiography
 Recording electrical activity of the
 Assessment of
 Cardiac rate and rhythm
 Status of the heart muscle
 Waves
Lab
Data
heart  P
QRS T