1. 1 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 2 The Physical Examination and Its Basis in Physiology The Physical Examination and Its Basis in Physiology

2. 2 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Vital Signs  Body temperature (T)  Pulse (P)  Respiration (R)  Blood pressure (BP)  Pulse oximetry (SpO 2 )

3. 3 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 2-1. Average Range for Vital Signs According to Age Group

4. 4 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Body Temperature

5. 5 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

6. 6 Four Common Types of Fever  Intermittent  Remittent  Relapsing  Constant

7. 7 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Box 2-1 Clinical Signs of Hypothermia  Below normal body temperature  Decreased pulse and respiratory rate  Severe shivering (initially)  Patient indicating coldness or presence of chills  Pale or bluish cool, waxy skin  Hypotension

8. 8 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Box 2-1 Clinical Signs of Hypothermia (Cont’d)  Decreased urinary output  Lack of muscle coordination  Disorientation  Drowsiness or unresponsiveness  Coma

9. 9 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Box 2-2 Common Therapeutic Interventions for Hypothermia  Remove wet clothing  Provide dry clothing  Place patient in a warm environment (e.g., slowly increase the room temperature)  Cover patient with a warm blanket or electric heating blanket

10. 10 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Box 2-2 Common Therapeutic Interventions for Hypothermia (Cont’d)  Apply warming pads (increase temperature slowly)  Cover patient’s head with a cap or towel  Supply warm oral or intravenous fluids

11. 11 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 2-2 Factors Affecting Body Temperature (see text for full discussion)  Age  Environment  Time of day  Exercise  Stress  Hormones

12. 12 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Body Temperature Measurements  The measurement of body temperature establishes an essential baseline for clinical comparison.  To ensure reliability of a temperature reading:  Select correct equipment  Choose the most appropriate site  Use the correct technique or procedure

13. 13 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Body Temperature Measurements (Cont’d)  The four most commonly used sites are the:  Mouth  Rectum  Ear (tympanic)  Axilla  Additional sites  Esophagus  Pulmonary artery

14. 14 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Core Temperature Sites  Rectum  Ear (tympanic)  Esophagus  Pulmonary artery

15. 15 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 2-3 Body Temperature Measurements: Summary of Body Temperature Sites, Advantages and Disadvantages, and Equipment Used

16. 16 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pulse  Rate  Rhythm  Strength

17. 17 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 2-1. Average Range for Vital Signs According to Age Group.

18. 18 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-2. The nine common pulse sites.

19. 19 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Box 2-3 Scale to Rate Pulse Quality 0: Absent or no pulse 1+: Weak, thready, easily obliterated with pressure; difficult to feel 2+: Pulse difficult to palpate; may be obliterated by strong pressure 3+: Normal pulse 4+: Bounding, easily palpated, and difficult to obliterate

20. 20 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Respiration

21. 21 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 2-1. Average Range for Vital Signs According to Age Group.

22. 22 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Common Breathing Patterns

23. 23 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Eupnea. Normal range and rhythm; 12 to 20 breaths/min in regular rhythm and of moderate depth for an adult. Time (15 seconds) Volume

24. 24 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Bradypnea. Regular rhythm of fewer than 12 breaths/min. Time (15 seconds) Volume

25. 25 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Tachypnea. Regular rhythm of more than 20 breaths/min for an adult. Time (15 seconds) Volume

26. 26 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Apnea. Absence of breathing that leads to respiratory arrest and death. Apnea Time (15 seconds) Volume

27. 27 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Hypoventilation. D ecreased rate and depth, decreasing alveolar ventilation and leading to an increased Pa CO 2. Time (15 seconds) Volume

28. 28 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Hyperventilation. Increased rate and depth, which increases alveolar ventilation and leads to a decreased Pa CO 2. Time (15 seconds) Volume

29. 29 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Cheyne-Stokes. Respirations become faster and deeper, then slower and shallower with a period of apnea. Apnea Time (15 seconds) Volume

30. 30 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Kussmaul’s. Increased rate and depth of breathing. Usually associated with diabetic ketoacidosis as a compensatory mechanism to eliminate excess carbon dioxide. Time (15 seconds) Volume

31. 31 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Biot’s. Fast, deep respirations with abrupt pauses. Apnea Time (15 seconds) Volume

32. 32 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Blood Pressure

33. 33 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 2-1. Average Range for Vital Signs According to Age Group.

34. 34 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Blood Pressure  The arterial blood pressure is the force exerted by the circulating volume of blood on the walls of the arteries  Systolic blood pressure  Diastolic blood pressure

35. 35 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  Function of:  Blood flow generated by ventricular contraction  Resistance to blood flow by the vascular system BP = V × R BP = V × R. Blood Pressure (Cont’d)

36. 36 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Blood Flow  Blood flow is equal to cardiac output  Cardiac output (CO) is equal to:  Volume of blood ejected from the ventricles during each heartbeat (stroke volume [SV]), multiplied by the heart rate (HR) CO = SV × HR CO = SV × HR  Average CO is about 5 L/min.

37. 37 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Blood Flow Abnormalities  Hypertension  Blood pressure is chronically above normal  Hypotension  Blood pressure falls below 90/60 mm Hg  Orthostatic hypotension  When blood pressure quickly drops as the individual rises to an upright position or stands

38. 38 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pulsus Paradoxus  ↓ Blood pressure during inspiration  ↑ Blood pressure during expiration

39. 39 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Oxygen Saturation  Often considered the fifth vital sign

40. 40 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 2-6. Sp O 2 and Pa O 2 Relationship for the Adult and Newborn

41. 41 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 2-7 Signs and Symptoms of Inadequate Oxygenation  Central Nervous System  Apprehension (early)  Restlessness or irritability (early)  Confusion or lethargy (early or late)  Combativeness (late)  Coma (late)

42. 42 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 2-7 Signs and Symptoms of Inadequate Oxygenation (Cont’d)  Respiratory  Tachypnea (early)  Dyspnea on exertion (early)  Dyspnea at rest (late)  Use of accessory muscles (late)  Intercostal retractions (late)  Takes a breath between each word or sentence (late)

43. 43 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  Cardiovascular  Tachycardia (early)  Mild hypertension (early)  Arrhythmias (early or late)  Hypotension (late)  Cyanosis (late)  Skin is cool or clammy (late) Table 2-7 Signs and Symptoms of Inadequate Oxygenation (Cont’d)

44. 44 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  Other  Diaphoresis (early or late)  Decreased urinary output (early or late)  General fatigue (early or late) Table 2-7 Signs and Symptoms of Inadequate Oxygenation (Cont’d)

45. 45 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Systematic Examination of the Chest and Lungs  Inspection  Palpation  Percussion  Auscultation

46. 46 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Lung and Chest Topography  Thoracic cage landmarks  Imaginary lines  Lung borders and fissures

47. 47 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Thoracic Cage Landmarks

48. 48 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-3. Anatomic landmarks of the chest.

49. 49 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Imaginary Lines

50. 50 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-4. Imaginary vertical lines on the chest.

51. 51 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Lung Borders and Fissures

52. 52 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-5. Topographic location of lung fissures projected on the anterior chest (A) and posterior chest (B).

53. 53 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Inspection  The inspection of the patient is an ongoing observation process that begins with the history and continues throughout the:  Patient interview  Taking of vital signs  Physical examination

54. 54 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Box 2-4. Common Clinical Manifestations Observed during Inspection

55. 55 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Palpation  Palpation is the process of touching the patient’s chest to evaluate the:  Symmetry of chest expansion  Position of the trachea  Skin temperature, muscle tone  Areas of tenderness, lumps, and depressions  Tactile and vocal fremitus

56. 56 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-6. Path of palpation.

57. 57 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Palpation  Chest excursion  Tactile and vocal fremitus

58. 58 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-7. Assessment of chest excursion. A, Anterior. B, Posterior. Note the thumbs move apart on inspiration as the volume of the thorax increases.

59. 59 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Percussion  Percussion over the chest wall is performed to determine the size, borders, and consistency of air, liquid, or solid material in the underlying lung.

60. 60 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-8. Chest percussion technique.

61. 61 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-9. Path of systematic percussion to include all important areas.

62. 62 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-10. Chest percussion of a normal lung.

63. 63 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Abnormal Percussion Notes  Dull percussion note  Pleural thickening  Pleural effusion  Atelectasis  Consolidation  Hyperresonant percussion note  Chronic obstructive pulmonary disease  Pneumothorax

64. 64 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-11. A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.

65. 65 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.

66. 66 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Diaphragmatic Excursion  Causes of minimal diaphragmatic excursion  Alveolar hyperinflation Examples: severe emphysema, bronchitis, asthma Examples: severe emphysema, bronchitis, asthma  Lobar collapse of one lung Lung is pulled up to the affected side, reducing excursion Lung is pulled up to the affected side, reducing excursion  Neuromuscular disease Diaphragm may be elevated and immobile Diaphragm may be elevated and immobile

67. 67 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Auscultation  Auscultation of the chest provides information about the heart, blood vessels, and air flowing in and out of the tracheobronchial tree and alveoli.

68. 68 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-13. Path of systematic auscultation to include all important areas. Note the exact similarity of this pathway to Figure 2-6.

69. 69 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Normal Breath Sounds  Bronchial breath sounds  Bronchovesicular breath sounds  Vesicular breath sounds

70. 70 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-14. The location at which bronchovesicular breath sounds (A) and vesicular breath sounds (B) are normally auscultated.

71. 71 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-15. Auscultation of vesicular breath sounds over a normal lung unit.

72. 72 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Adventitious (Abnormal) Breath Sounds  Bronchial breath sounds  Diminished breath sounds  Crackles and rhonchi  Wheezing  Pleural friction rubs  Stridor  Whispering pectoriloquy

73. 73 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Bronchial Breath Sounds  Described as loud “bronchial-type” sounds  Causes  Alveolar consolidation  Atelectasis

74. 74 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung unit.

75. 75 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Diminished Breath Sounds  Causes  Air trapping (e.g., emphysema, bronchitis, asthma)  Flail chest  Pneumothorax  Pleural effusion  Neuromuscular diseases Guillain-Barré syndrome Guillain-Barré syndrome Myasthenia gravis Myasthenia gravis

76. 76 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive lung diseases, breath sounds progressively diminish.

77. 77 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Crackles and Rhonchi  Crackles (rales)—are usually fine or medium crackling wet sounds  Typically heard during inspiration  May or may not change in nature after a strong and vigorous cough  Rhonchi—usually have a coarse, “bubbly” quality  Typically heard during expiration  Often change in nature or disappear after a strong and vigorous cough

78. 78 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Wheezing  High-pitched and whistling sound  Generally heard during expiration  Most common cause  Bronchospasm

79. 79 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-18. Wheezing and rhonchi often develop during an asthmatic episode because of smooth muscle constriction, wall edema, and mucous accumulation.

80. 80 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pleural Friction Rubs  The sound is reminiscent of that made by a creaking shoe  Commonly heard over the area where the patient complains of pain  Cause  Inflamed pleural membranes

81. 81 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Stridor  Abnormal audible high-pitched musical sound caused by an obstruction in the trachea or larynx  Generally heard during inspiration  Causes  Acute epiglottis  Laryngotracheobronchitis

82. 82 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Whispering Pectoriloquy  Term used to describe the unusually clear transmission of the whispered voice of a patient as heard through the stethoscope  Causes  Atelectasis  Consolidation

83. 83 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-19. Whispered voice sounds auscultated over a normal lung are usually faint and unintelligible.

84. 84 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-20. Whispering pectoriloquy. Whispered voice sounds heard over a consolidated lung are often louder and more intelligible compared with those of a normal lung.

85. 85 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  Inspection  Pursed lip breathing  Tripod position; inability to lie flat  Accessory muscle use; intercostal retractions  Splinting  AP diameter  Tachypnea  Kussmaul’s respiration Modified from Lewis S, Heitkemper MM, Dirksen SR: Medical-surgical nursing: assessment and management of clinical problems, ed 7, vol 1, St Louis, 2007, Mosby. Table 2-8 Common Assessment Abnormalities

86. 86 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 2-8 Common Assessment Abnormalities (Cont’d)  Inspection  Cyanosis  Clubbing finger  Peripheral edema  Distended neck veins  Cough  Sputum (amount, color, smell)  Abdominal paradox Modified from Lewis S, Heitkemper MM, Dirksen SR: Medical-surgical nursing: assessment and management of clinical problems, ed 7, vol 1, St Louis, 2007, Mosby.

87. 87 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  Palpation  Tracheal deviation  Altered tactile fremitus  Altered chest movement  Percussion  Hyperresonance  Dullness Modified from Lewis S, Heitkemper MM, Dirksen SR: Medical-surgical nursing: assessment and management of clinical problems, ed 7, vol 1, St Louis, 2007, Mosby. Table 2-8 Common Assessment Abnormalities (Cont’d)

88. 88 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  Auscultation  Fine crackles  Coarse crackles  Rhonchi  Wheezes  Stridor  Absent breath sounds  Pleural friction rub  Whispered pectoriloquy  Bronchophony   Egophony Modified from Lewis S, Heitkemper MM, Dirksen SR: Medical-surgical nursing: assessment and management of clinical problems, ed 7, vol 1, St Louis, 2007, Mosby. Table 2-8 Common Assessment Abnormalities (Cont’d)

89. 89 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Normal Ventilatory Pattern Composed of:  Tidal volume  About 500 mL (7 to 9 mL/kg)  Ventilatory rate  About 15 breaths/min (range 12 to 18 breaths/min)  Inspiratory-to-expiratory (I:E) ratio  About 1:2

90. 90 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Use of the Accessory Muscles of Inspiration  Scalene  Sternocleidomastoid  Pectoralis major  Scalenes

91. 91 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-33. The scalene muscles.

92. 92 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-34. The sternocleidomastoid muscle.

93. 93 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-35. The pectoralis major muscles.

94. 94 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-36. The way a patient may appear when using the pectoralis major muscles for inspiration.

95. 95 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-37. The trapezius muscles.

96. 96 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-38. The action of the trapezius muscle is typified in shrugging the shoulders.

97. 97 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Use of the Accessory Muscles of Expiration  Rectus abdominis  External oblique  Internal oblique  Transversus abdominis

98. 98 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-39. Accessory muscles of expiration. Arrows indicate the action of these muscles in enlarging the volume of the lungs.

99. 99 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-40. When the accessory muscles of expiration contract, intrapleural pressure increases, the chest moves outward, and airflow increases.

100. 100 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pursed-Lip Breathing

101. 101 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-41. A, Schematic illustration of alveolar compression of weakened bronchiolar airways during normal expiration in patients with chronic obstructive pulmonary disease (e.g., emphysema). B, Effects of pursed-lip breathing. The weakened bronchiolar airways are kept open by the effects of positive pressure created by pursed lips during expiration.

102. 102 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Substernal and Intercostal Retractions

103. 103 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-42. Intercostal retraction of soft tissues during forceful inspiration.

104. 104 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Nasal Flaring

105. 105 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Splinting Caused by Chest Pain or Decreased Chest Expansion  Pleuritic chest pain  Sudden, sharp, or stabbing pain  Nonpleuritic chest pain  Constant pain that is located centrally

106. 106 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-43. When the parietal pleura is irritated, the nerve endings in the parietal pleura send pain signals to the brain.

107. 107 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pleuritic Chest Pain  Associated with:  Pneumonia  Pleural effusion  Pneumothorax  Pulmonary infarction  Lung cancer  Pneumoniosis  Fungal diseases  Tuberculosis

108. 108 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Nonpleuritic Chest Pain  Associated with:  Myocardial ischemia  Pericardial inflammation  Pulmonary hypertension  Esophagitis  Local trauma or inflammation of the chest cage, muscles, bones, or cartilage

109. 109 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 2-10. Common Abnormal Chest Shapes and Configurations

110. 110 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-44. A, Normal anteroposterior diameter. B, Barrel chest.

111. 111 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Abnormal Extremity Findings  Altered skin color  Cyanosis  Digital clubbing  Peripheral edema  Distended neck veins

112. 112 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-45. Cyanosis is likely whenever the blood contains at least 5 g of reduced hemoglobin. In the normal individual who has about 15 g of hemoglobin per 100 mL of blood, a P O 2 of about 30 mm Hg produces 5 g of reduced hemoglobin. The hemoglobin, however, is still approximately 60% saturated with oxygen.

113. 113 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Digital Clubbing Figure 2-46. Digital clubbing.

114. 114 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-47. Pitting edema. (From Bloom A, Ireland J: Color atlas of diabetes, ed 2, London, 1992, Mosby-Wolfe.)

115. 115 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Distended Neck Veins Figure 2-48. Distended neck veins (arrows).

116. 116 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Normal and Abnormal Sputum Production

117. 117 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Normal Histology and Production of Mucus in the Tracheobronchial Tree

118. 118 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-49. The normal lung. ALV, Alveoli; BM, basement membrane; BR, bronchioles; C, cartilage; EP, epithelium; GC, goblet cell; MC, mast cell; PA, pulmonary artery; PN, parasympathetic nerve; RB, respiratory bronchioles; SG, submucosal gland; SM, smooth muscle; TBR, terminal bronchioles.

119. 119 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 2-50. The epithelial lining of the tracheobronchial tree.

120. 120 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Abnormal Sputum Production

121. 121 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 11-1. Chronic bronchitis, one of the most common airway diseases. AWO, Airway obstruction; ESG, enlarged submucosal gland; HALV, hyperinflation of alveoli (distal to airway obstruction); IEP, inflammation of epithelium; MA, mucous accumulation; MP, mucous plug.

122. 122 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 2-11. Analysis of Sputum Color

123. 123 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Cough

124. 124 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

125. 125 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Nonproductive Cough  Common causes  Irritation of the airways  Inflammation of the airways  Mucous accumulation  Tumors  Irritation of the pleura

126. 126 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Productive Cough  Assess the following:  Is the cough strong or weak?  Evaluate cough for: Frequency Frequency Pitch Pitch Loudness Loudness  Evaluate sputum for: Amount Amount Odor Odor Color Color