Chapter 15 Bedside Assessment of the Patient

Chapter 15 Bedside Assessment of the Patient
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Learning Objectives Describe why patient interviews are necessary and the appropriate techniques for conducting an interview. Identify abnormalities in lung function associated with common pulmonary symptoms. Identify breathing patterns associated with underlying pulmonary disease. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Learning Objectives (cont.)
Differentiate between dyspnea and breathlessness. Identify terms used to describe normal and abnormal lung sounds. Describe the mechanisms responsible for normal and abnormal lung sounds. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Learning Objectives (cont.)
Explain why it is necessary to examine the precordium, abdomen, and extremities in a patient with cardiopulmonary disease. Describe some of the common abnormalities found during the exam of the precordium, abdomen, and extremities in patients with cardiopulmonary disease. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Introduction Bedside assessment—process of interviewing & examining patient for signs & symptoms of disease Inexpensive & little risk to patient Part of initial assessment to identify diagnosis & to evaluate ongoing effects of treatment 2 key sources of patient data: Medical history Physical examination Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Interviewing Purposes Establish rapport with patient
Obtain essential diagnostic information Help monitor changes in patient’s symptoms & response to therapy Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Helps identify the need for subsequent diagnostic tests
All of the following are reasons why a clinician should review a patient’s medical history and perform a physical examination, except: Helps identify the need for subsequent diagnostic tests Helps select the best approach for therapy Helps monitor patient’s progress toward predefined goals Determines how long the patient will remain in the hospital Answer: D Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Interviewing (cont.) Technique
Introduce yourself in social space (~4-12 feet) Interview in personal space (~2-4 feet) Use appropriate eye contact Assume physical position at same level as patient Avoid use of leading questions; use neutral questions Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Interviewing (cont.) Common questions to ask for each symptom:
When did it start? How severe is it? Where on body is it? What seems to make it better or worse? Has it occurred before? Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Cardiopulmonary Symptoms
Dyspnea Sensation of breathing discomfort by patient (subjective feeling) Most important symptom RT is called upon to assess & treat Breathlessness Sensation of unpleasant urge to breathe Can be triggered by acute hypercapnia, acidosis & hypoxemia Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Dyspnea Subjective experience. Should not be inferred from observing patient`s breathing pattern Orthopnea: dyspnea in reclining position; associated w/ CHF Platypnea: dyspnea in upright position associated w/ arteriovenous malformation Degree of dyspnea is evaluated by asking about level of exertion at which it occurs Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Cardiopulmonary Symptoms (cont.)
Language of Dyspnea Ask patient about quality & characteristics of dyspnea (may provide insight into its causes) Patients w/ asthma frequently complain of chest tightness Patients w/ interstitial lung disease may complain of increased WOB, shallow breathing & gasping Patients w/ CHF may complain of feeling suffocated Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Assessing dyspnea during an interview: Pay attention to whether patient can speak in full sentences Questions should be brief & limited to quality & intensity of dyspnea & circumstances of symptom onset Assessment should correspond with gross examination of patient’s breathing pattern Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Psychogenic Dyspnea: Panic Disorders & Hyperventilation Patients have normal cardiopulmonary function of intense dyspnea & suffocation May coincide w/ symptoms, such as chest pain, anxiety, palpitation & paresthesia Anxiety often accompanied by breathlessness & hyperventilation Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

A patient with congestive heart failure, complains that when he assumes a reclining position he begins to feel dyspneic, what kind of condition is this patient describing? Platypnea Orthopnea Apnea Eupnea Answer: B Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Cough Cough occurs when cough receptors in airways are stimulated by inflammation, mucus, foreign material, or noxious gases Weak cough is often due to high Raw, poor lung recoil, weak muscles or pain Patients with airways disease often have loose, productive cough Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

All of the following are common causes of a weak cough effort, except:
steroid administration high airway resistance (Raw) weak respiratory muscles poor lung recoil Answer: A Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Sputum production Mucus from tracheobronchial tree not contaminated by oral secretion is called “phlegm” Mucus from lower airways but is expectorated through mouth is called “sputum” Sputum having pus cells is said to be “purulent” Foul smelling sputum is “fetid” Recent changes in sputum color, viscosity, or quantity may indicate infection Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Hemoptysis Coughing up blood or bloody sputum Characterized—massive or non-massive Massive More than 300 ml of blood expectorated over 24 hours Common causes: bronchiectasis, lung abscess, & acute or old tuberculosis Distinguished from hematemesis (vomiting blood from gastrointestinal tract) Non-massive Common causes include: infection of airway, tuberculosis, trauma, & pulmonary embolism Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Chest pain Pleuritic chest pain—located laterally or posteriorly - sharp in nature, & increases w/ deep breathing (pneumonia & pulmonary embolism) Nonpleuritic chest pain—located in center of chest & may radiate to shoulder or arm—often caused by coronary artery disease & known as angina in such cases (other causes: gastroesophageal reflux & esophageal spasm) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Fever Elevation of body temperature due to disease May occur w/ simple viral infection of upper airway or with serious bacterial pneumonia, tuberculosis, & some cancers Causes increased metabolic rate, oxygen consumption & carbon dioxide production Particularly dangerous in patients w/ severe chronic cardiopulmonary disease, as it may cause acute respiratory failure Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Pedal edema Swelling of lower extremities - most often due to heart failure 2 subtypes; Pitting edema—indentation mark left on skin after applied pressure Weeping edema—small fluid leak occurs at point where pressure applied Patients w/ chronic hypoxemic lung disease usually develop right heart failure (cor pulmonale) due to pulmonary hypertension Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Pleuritic chest pain can be associated with all these diseases, except:
Pneumonia Pulmonary Embolism Costochondritis Pneumothorax Answer: C Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Medical History Familiarizes clinician w/ patient’s condition
Reviewing patient’s chart: Chief complaint (CC)/ history of present illness (HPI)—explains current medical condition Past medical history (PMI) Review of systems (ROS) Social/Environmental history Advance directive Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Medical History (cont.)
RT’s priority—ensure all respiratory care procedures are supported by physician order (current, clearly written & complete) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

65 year-old female states that she has been smoking for 40 years and approximately 1/2 pack of cigarette per day. How would you document this patient’s smoking history for the record? 10 pack-year 20 pack-year 30 pack-year 40 pack-year Answer: B Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Physical Examination Essential for evaluating patient’s problem & determining ongoing effects of therapy Consists of 4 steps: Inspection (visually examining) Palpation (touching) Percussion (tapping) Auscultation (listening with stethoscope) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

General Appearance Done during first few seconds of patient encounter
Indicators to assess: Level of consciousness Facial expression Level of anxiety or distress Body positioning Personal hygiene Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Level of Consciousness
Sensorium: Level of consciousness & orientation to time, place, person & situation (oriented x 4) Reflects oxygenation status of brain Affected by poor cerebral blood flow (hypotension) If patient not alert—standard rating scale is used to objectively describe patient’s level of consciousness (Box 15-5, p. 338) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Vital Signs (VS) Easy to obtain & provide useful information about current health status VS provide first clue to adverse reactions to treatment Vital Signs = RR, HR, BT, BP Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Body Temperature Normal: 98.6 oF or 37.0 oC
Increased temperature: Hyperthermia or hyperpyrexia (fever) Decreased temperature: Hypothermia Can be measured at: mouth, axilla, ear or rectum Rectal temp: closest to core body temperature Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

A patient presents to the ER complaining of chills and profuse sweating for the last two days. A rectal temperature shows 102.3oF. This patient is said to be: Hypothermic Febrile Confused Emaciated Answer: B Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Heart Rate (HR) Evaluate rate, rhythm & strength
Tachycardia: HR>100 beats/min.Treat causes first Bradycardia: HR<60 beats/min Measure for full minute if pulse is irregular Pulsus paradoxus vs. pulsus alternans Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Respiratory Rate (RR) Resting adult RR is 12 to 18 breaths per minute (bpm) Tachypnea >20 bpm Bradypnea <10 bpm Do not reveal assessment of RR to patient Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Blood Pressure (BP) Systolic: 90 to 140 mmHg Diastolic: 60 to 90 mmHg
Pulse pressure: difference between systolic & diastolic. Usually 30 to 40 mmHg Hypertension: BP persistently >140/90 Hypotension: Systolic BP <90 mmHg or mean art. pressure <65 mmHg Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Head & Neck Exam Head Abnormal signs help indicate respiratory problems Nasal flaring: often seen in infants w/ respiratory distress—increased WOB Cyanosis of oral mucosa (central cyanosis) indicates respiratory failure due to low oxygen levels Pursed-lip breathing—seen in patients w/ COPD to prevent collapse of small airways Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Head & Neck Exam (cont.) Neck
Trachea should be midline;may shift away from midline in certain thoracic disorders Jugular venous distention (JVD) is seen in patients w/ CHF & cor pulmonale Enlarged lymph nodes in neck may occur w/ infection or malignancy Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

pulmonary hypertension
A COPD patient arrives in the ER complaining of swollen ankles and shortness of breath while laying flat. On physical exam a positive JVD is noted. You should suspect all of the following, except: right heart failure cardiac tamponade cor pulmonale pulmonary hypertension Answer: B Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Examination of Thorax (cont.)
Pectus carinatum—abnormal protrusion of sternum Pectus excavatum—abnormal depression of sternum Kyphoscoliosis—abnormal curvature of spine; often causes severe restrictive lung disease Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Examination of Thorax (cont.)

Breathing Pattern Abnormal breathing pattern—broken into 2 broad categories: Associated w/ thoracic or pulmonary disease that increases WOB (asthma) Associated w/ neurologic disease (central sleep apnea) Rapid & shallow breathing is consistent w/ restrictive lung diseases Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Breathing Pattern (cont.)
Prolonged expiratory time—consistent w/ obstructive lung disease Upper airway obstruction often causes prolonged inspiratory time Deep & fast breathing is consistent with Kussmaul breathing (ketoacidosis) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Diaphragmatic Fatigue
Found in many types of chronic & acute pulmonary diseases Signs of acute fatigue: Tachypnea Diaphragm & rib cage muscles take turns powering breathing (respiratory alternans) Abdominal paradox occurs w/ complete diaphragmatic fatigue Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

All of these are common causes of an abnormal breathing pattern associated with thoracic or pulmonary disease that increases work of breathing, except: Central sleep apnea COPD Asthma Pulmonary edema Answer: A Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Chest Palpation Vocal & tactile fremitus is increased w/ pneumonia & atelectasis (consolidation) Vocal & tactile fremitus is reduced w/ emphysema, pneumothorax, & pleural effusion Bilateral reduction in chest expansion—seen in neuromuscular disorders & COPD Unilateral reduction in chest expansion: consistent w/ pneumonia or pneumothorax Air leaks into subcutaneous tissues causes “crepitus”—sign of subcutaneous emphysema Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Chest Percussion Resonance of chest evaluated w/ percussion
Findings should be labeled as “normal,” “increased,” or “decreased” resonance Decreased resonance—pneumonia or pleural effusion (consolidation) Increased resonance—emphysema or pneumothorax (air) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Chest Auscultation Lung sounds come in 2 varieties
Breath sounds Adventitious lung sounds Breath sounds = normal sounds of breathing Adventitious lung sounds = abnormal sounds Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Chest Auscultation (cont.)
Breath sounds Tracheal breath sounds: heard directly over trachea; created by turbulent flow; loud with expiratory component equal to or slightly longer than inspiratory component Bronchovesicular breath sounds: heard around sternum; softer & slightly lower in pitch Vesicular breath sounds: heard over lung parenchyma; very soft & low-pitched Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Breath sounds Reduced w/ shallow breathing; when attenuation is increased (when lung is hyperinflated—emphysema) Increased when attenuation is reduced & turbulent flow sounds pass through lung faster (pneumonia) Increased breath sounds often called “bronchial” breath sounds Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Adventitious lung sounds 2 varieties: Discontinuous Intermittent crackling Bubbling sounds of short duration Referred to as “crackles” Continuous Referred to as “wheezes” Heard over the upper airway is called “stridor” Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Bronchial breath sounds Abnormal if heard over peripheral lung regions Replacing normal vesicular sounds when lung tissue density increases Diminished breath sounds Occur when sound intensity at site of generation (larger airways) is reduced due to shallow or slow breathing, or When sound transmission through lung or chest wall is decreased (COPD or asthma) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Wheezes are Consistent w/ airway obstruction Monophonic wheezing indicates one airway is affected Polyphonic wheezing indicates many airways are involved Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Stridor Upper airway compromised Chronic stridor—laryngomalacia Acute stridor—croup Inspiratory stridor—narrowing above glottis Expiratory stridor—narrowing of lower trachea Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Coarse crackles Airflow moves secretions or fluid in airways Usually clears when patient coughs or upper airway is suctioned Fine crackles Sudden opening of small airways in lung deep breathing Heard w/ pulmonary fibrosis & atelectasis Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

What condition may cause an RT to hear sudden high-pitched popping noises during the late-inspiration phase? Atelectasis Asthma Croup Bronchitis Answer: A Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Cardiac Examination Chest wall overlying heart is known as precordium
Inspected, palpated, & auscultated for abnormalities Right ventricular hypertrophy causes an abnormal pulsation can be seen & felt near lower margin of sternum; consistent w/ cor pulmonale (COPD) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Cardiac Examination (cont.)
Heave is abnormal pulsation felt over precordium Murmur is abnormal heart sound, often heard over precordium Murmurs produced by blood flowing through narrowed opening Systolic murmurs caused by stenotic semilunar valves & incompetent AV valves Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Diastolic murmurs caused by stenotic AV valves or incompetent semilunar valves Murmurs may also be created by rapid blood flow through normal valve in healthy people during heavy exercise Murmurs in babies may suggest cardiovascular abnormalities related to inadequate adjustment to extrauterine life Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

S1: created by closure of AV valves S2: created by closure of semilunar valves S3: abnormal in adults & caused by rapid filling of stiff left ventricle S4: caused by atrial “kick” of blood into noncompliant left ventricle When patient has both S3 & S4—gallop rhythm is present Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Abdominal Exam Abdomen inspected & palpated for distention tenderness
Abdominal compartment syndrome – when intra-abdominal pressures >20mmHg. An enlarged liver (hepatomegaly) is consistent with cor pulmonale. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Examination of Extremities
Digital clubbing (not common) - seen in large variety of chronic conditions: congenital heart disease, bronchiectasis, various cancers, & interstitial lung diseases Fig 15-10 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Examination of Extremities (cont.)
Digital cyanosis (acrocyanosis): often sign of poor perfusion; hands& feet typically cool to touch in such cases Acrocyanosis occurs frequently in newborns; usually disappears w/in 24 to 72 hrs after birth Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Chapter 15 Bedside Assessment of the Patient

Similar presentations

Presentation on theme: "Chapter 15 Bedside Assessment of the Patient"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Chapter 15 Bedside Assessment of the Patient

Similar presentations

Presentation on theme: "Chapter 15 Bedside Assessment of the Patient"— Presentation transcript:

Similar presentations

About project

Feedback