1. LOG #2 Signs and Symptoms
Patient Assessment
LOG #2
Signs and Symptoms

2. Cough Most common symptom in patients with pulmonary disease Purpose
Aids in removal of materials from the respiratory tract by providing high-velocity airflow on expiration
Protective mechanism

3. Cough Irritants 1. Secretions Post-nasal drip
Secretions from the lung inflammatory response
2. Inspired irritants
Cigarette smoke, chemicals, food, cold air, fumes
3. Tumour
4. Airway hyperactivity
Asthma, (some COPD)
Secretions = infections (inflammation) e.g. pneumonia, bronchitis, left heart failure, post nasal drip.
Inspired Irritants = cigarette smoke, cold air, chemicals/gasses.
Tumour = lung, throat.
Airway hyperactivity = asthma.

4. Types of Cough 1. Upper airway problems Barking, hoarse 2. Bronchial
Wheezy, whistling
3. Broncho-pulmonary disease
Chronic
4. Smoking, viral, nervous, and PND
Upper airway = barking, hoarse
bronchial = wheezy (whistling)
Broncho-pulmonary disease = chronic, productive
Smoking, viral, nervous, and PND = hacking (frequent periods of coughing or clearing throat)

5. Cough Reflex
A reflex that arises from stimulation of cough or irritant receptors
Receptors located in
Pharynx
Larynx
Trachea
Large bronchi
Visceral pleura

6. Cough Reflex cont. When stimulated
Receptors send a signal via glossopharyngeal (IX) and Vagus (X) nerves to the cough reflex centre in the medulla (centre in the brain)
The medulla then causes the glottis to close and accessory muscles of expiration to contract

7. Cough Mechanism 1. Stimulation 2. Deep breath – 3. Inspiratory pause –
2. Deep Breath = effectiveness of cough guideline =
a) insp. capacity greater than 75%
b) vital capacity greater than 15 mls. /kg
3. Inspiratory Pause = aids gas distribution and therefore mucus mobilization
4. Glottic closure
5. Compression phase = contraction of expiratory muscles
increased intrathoracic pressure
trapped air in lungs is compressed
6. Glottic opening = blast of air rushes upward at high velocity, therefore transports mucus.

8. Cough Mechanism cont. 4. Glottic closure (Compression phase) –
5. Glottic opening –

9. Coughing cont.
Valsalva manoeuvre
Increased intrathoracic pressure by forcible exhalation against a closed glottis.
Efficiency of cough determined by
Depth of inspiration
Amount of pressure generated. Depends on –
The cough mechanism = Valsalva manoeuvre

10. Hazards of Coughing 1. Cough syncope – 2. Pneumothorax 3. Hemoptysis
4. Spread of infection
5. Rib fracture
Others not as common
Torn chest muscles
Urinary incontinence
Esophageal rupture
Cough syncope (vaso vagal) = increased intrapulmonary pressure = decreased venous return = decreased cardiac output = cerebral ischemia
Pneumothorax = rib fracture
Aka vasovagal syncope = loss of consciousness due to increased vagus nerve activity (paraympathetic)

11. Productive vs. Non-Productive
Secretions
Blood
Non-Productive
Irritation (non-expectorating)
May be due to inflammation, growth, reflex
Effective Cough – Strong enough to clear secretions
Ineffective Cough – Inefficient or unable to clear secretions

12. Expectoration Sputum comprised of Mucus Sol layer – Gel layer – Others
WBC
Blood
Aspirate
Dead tissue cells
Pharyngeal
Sputum –
Phlem –
Gel layer = top, gelatanous
Sol layer= liquid colloid

13. Important Aspects of Sputum Expectoration
1. Colour
Clear –
Yellow –
White/yellow –
Green –
Red –
Brown –
Pink/frothy –
Black/grey –
Clear = normal
white/mucoid = asthma
yellow = WBC (Pus)= infectlion
Green= stagnant pus, old infection
Yellow and Green copious = purulent
Creamy and stringy = mucopurulent, infectopmj, cf, pneumonias
red = blood
brown, rusty= old blood, certain pneumonias
pink frothy = pulmonary edema
Black = smoke or coal dust
foul smelling = abscess, bronchiectasis, anaerobic infections, aspiration
Bronchiectasis = separates into layers

14. Expectoration cont. 2. Consistency 3. Volume Watery Thick Sticky Solid
24-hour period
How much?

15. Expectoration cont. 4. Odour 5. When Foul (Anaerobic) A.M / P.M?
Irritants

16. Potential Hazards of Retained Secretions
1. Inflammation
Increased Raw (Airway resistance)
Increased WOB
2. Partial airway plugging
Uneven distribution of ventilation
Shunt effect (perfusion in excess of ventilation)
Hypoxemia

17. Hazards cont. No ventilation Atelectasis
3. Total airway plugging
No ventilation
Atelectasis
Decreased Cl, therefore increased WOB
Shunting, therefore hypoxemia

18. Hemoptysis Definition Etiology Expectoration of fresh blood
Massive hemoptysis = greater than 600 mls. /24 hrs.
Etiology
1. Neoplasm –
2. Infection –
3. Cardiovascular –
4. Pulmonary embolism –
Neoplasm = Bronchogenic carcinoma, pulmonary lesion
Infection = TB, absess, pneumonia, Bronchiectasis, CF
Cardiovascular = pulmonary embolism, CHF, Mitral stenosis

19. Patient Assessment Signs and Symptoms
Dyspnea

20. Dyspnea
Patient awareness of difficulty in breathing or S.O.B. in an inappropriate setting
At rest
Activities of daily living
Sleeping
Speaking
Bathing

21. Causes Upper airway obstruction Asthma C.O.P.D Pulmonary fibrosis
1.Altered lung mechanics
Increased Raw
Upper airway obstruction
Asthma
C.O.P.D
Decreased compliance
Pulmonary fibrosis
Congestion
Edema
Atelectasis

22. Dyspnea Causes cont. Hypoxemia Hypercapnea Acidemia
2. Increased ventilation
Hypoxemia
Hypercapnea
Acidemia
Cardiac dysfunction

23. Dyspnea Causes cont. Weakness Paralysis Atrophy
3. Respiratory muscle abnormalities
Weakness
Paralysis
Atrophy

24. Dyspnea Causes cont. Pneumothorax Pleural effusion
4. Mechanical interference to expansion of lungs
Pneumothorax
Pleural effusion
5. Psychogenic

25. Dyspnea Variations Heart failure Advanced pulmonary disease
Orthopnea
Dyspnea while lying down
Heart failure
Advanced pulmonary disease
Paroxysmal nocturnal dyspnea
Sudden onset of S.O.B at night (in a sleeping pt.)
Cardiac patients

26. Exertional dyspnea
Dyspnea developed upon exertion in a normal situation

27. Patient assessment Signs and Symptoms
Cyanosis

28. Definition
Bluish discolouration of skin and mucous membranes

29. Due To An excess of deoxygenated hemoglobin in the blood
Usually greater than 50 gm/L of unsaturated Hb (Normal = gm/L)

30. Central vs. Peripheral Under tongue Conjunctiva of the eye Lips
Central – (Pt trunk and oral mucosa)
High vascular areas
Under tongue
Conjunctiva of the eye
Lips

31. Central cont. Decreased PaO2 (less than 50 mmHg)
Decreased pulmonary or cardiac Fx
Good indicator of hypoxemia

32. Peripheral Fingertips Toes Normal PaO2 (Mostly)
Decreased peripheral circulation
Cold (Vasoconstriction)
Perfusion (Decreased cardiac output)

33. To Differentiate Central and Peripheral
ABGs
Check sublingual cyanosis

34. So Clinically… Cyanosis = PaO2 less than 50 mmHg SaO2 less than 80%
*LATE SIGN OF HYPOXEMIA*

35. Note Polycythemic pt. may have cyanosis with only mild hypoxemia
Conversely
Anemic pt. may be severely hypoxemic and not cyanotic

36. Patient assessment Signs and Symptoms
Chest Pain

37. Chest Pain Pain primarily due to Pulmonary Cardiac
Mediastinal conditions

38. 1. Pulmonary Chest wall Parietal pleura Localized Constant aching
Any movement
E.g. rib #
Parietal pleura
Inspiratory pain
Sharp and severe
Localized
E.g. pleurisy

39. 2. Cardiac Major symptom of cardiac disease
Pain is usually diffuse, dull, and radiating
E.g. angina or infarction

40. 3. Mediastinal Burning substernal pain May radiate
Often assumed to be cardiac
E.g. esophagitis

41. Assessing Chest Pain MIDTERM #1 up to here!! Onset Location Radiation
Frequency
Duration
MIDTERM #1 up to here!!
Severity precipitation
Relieving factors
Description