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Assessing The Patient Robert Harwood, MHA, RRT-NPS

Objectives At the end of this presentation the student should be able to:

•  Assess general appearance of a patient’s head, neck and face, including venous distention, edema, accessory muscle activity, chest wall movement, diaphoresis, clubbing, cyanosis and breathing pattern

•  Assess the patient’s airway, including macroglassia and neck range of motion

•  Collect and evaluate clinical information concerning cough, sputum, and the character and amount of sputum

•  Evaluate a patient’s condition using Apgar score, gestational age, and transillumination of the chest

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General Appearance • General appearance characteristics:

Facial expression- pain Body position- tripod (COPD) Distress, diaphoresis- short of breath Look of anxiousness- hypoxia Malnutrition, emaciated, generally ill (cachexia)- COPD

• Questions with these characteristics, you would want to treat and stabilize the patient

Examination of Head and Neck Respiratory disease signs:

• Nasal flaring-increased flow rate • Cyanosis: Central vs. Peripheral

§ Central Need: requires oxygen Location: lips, nose, ears, neck region, tongue Darker pigmentation more difficult to see Look at palm of hands, oral cavity, tongue

§ Peripheral or acrocyanosis Poor circulation to extremities- cool

• Pursed-lip breathing

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Sample Question

A patient is receiving oxygen by nasal cannula at 3 L/minute. Upon inspection you notice the patient to have central cyanosis. This would indicate the presence of cyanosis to be: a. In the feet and ankles b. In the neck region and lips c. In the hands, fingers and wrists d. From the knees to the ankles

Sample Question Answers b. Correct answer-Neck region, lips, tongue, ears

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Examination of Head and Neck

• EYES • Normal- pupils equal, round, reactive to light PERRLA • Dilated and fixed pupils- brain death - Miadriasis • Pinpoint pupils - Miosis (opiates) • Double vision - Diplopia • Neuromuscular disease, e.g. Myasthenia gravis

Examination of Head and Neck • NECK

• Normal tracheal position: midline Assess: palpation of suprasternal notch

• Abnormal tracheal position Shift toward affected lung - pull

Shift away from affected lung - push

Severe Atelectasis

Pneumothorax, pleural effusion

Opposite Lung

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Examination of Head and Neck •  Jugular Venous Pressure

•  Level of column of blood in jugular vein reflects:

•  Abnormal conditions Right sided heart failure from:

Head elevated 45° degrees-distention 3-4 cm above sternal angle to angle of the jaw is abnormal

Volume Pressure Right Heart

Chronic hypoxemia-COPD Secondary to left-sided heart failure-CHF

Sample Question A male COPD patient is being assessed in the ICU following admission for acute exacerbation of his condition. The patient is lying in bed with the head of the bed at a 45° angle. Upon inspection, it is noticed that the jugular vein is distended to the jaw line. This finding would indicate the presence of which of the following? a. Anemia b. Polycythemia c. Kidney failure d. Right-sided heart failure

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Sample Question Answer d. Correct answer. Right sided heart failure can occur from

chronic hypoxemia or 2nd to CHF.

Examination of Thorax •  Inspection to determine

Normal thorax: Anterior Posterior (AP) diameter < transverse diameter Abnormal AP diameter = barrel chest

Common in COPD (emphysema), CF Ribs loose normal 45º angle = horizontal

•  Other Abnormal Thorax Inspection Pectus carinatum - chest characterized by a protrusion of the sternum and ribs Pectus excavatum - a caved-in or sunken appearance of the chest Kyphosis - over-curvature of the thoracic vertebrae (upper back) Scoliosis - person's spine is curved from side to side Kyphoscoliosis - combination of kyphosis and scoliosis Flail chest - detachment of the rib cage from the chest wall causing the flail segment to move in the opposite direction as the rest of the chest 2-2 rule: two ribs broken in 2 adjacent places

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Accessory Muscle Activity •  Indicates need for greater air flow • Patient has an increased work of breathing • Associated with diaphoresis, increased heart rate, desaturation • Cardiopulmonary disease increased use of accessory muscles of

inspiration and expiration • Retractions- increased airway resistance and decreased lung

compliance Substernal retractions Intercostal retractions

Sample Question Upon inspection of the head, neck and thorax, you notice the patient has respiratory distress and increased work of breathing. Which of the following would be present to indicate this finding?

I. Nasal flaring II. Pitting edema III. Jugular vein distention IV. Intercostal retractions a. I, II b. I, IV c. I, II, III d. I, II, III, IV

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Sample Question Answers b. Correct. Nasal flaring and intercostal retractions are

associated with increased work of breathing

Breathing Patterns Breathing Pattern

Cause Description

Apnea Respiratory or cardiac arrest Cessation of breathing

Biot’s High ICP Irregularity with breathing/long apnea spells

Kussmaul’s Metabolic acidosis Fast and deep (>20 bpm)

Cheyne-Stoke’s CHF, CNS disorders Increase and decrease breathing rate and volume, periods of apnea

Paradoxical Trauma, paralysis of diaphragm Affected area moves in with inspiration opposite of the rest of the lung.

Tachypnea Anxiety, hypoxemia Fast, shallow

Bradypnea Sedation, hypoxemia Abnormally slow breathing (<12 bpm)

Hyperpnea Fever, pain Deep breathing

Hypopnea Sedation Shallow and slow breathing

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Sample Question A patient has returned from a procedure requiring administration of a sedative. After evaluating the patient, the respiratory therapist charts that the patient has hypopnea. This type of breathing pattern would be associated with which of the following? a. Fast and shallow b. Irregular breathing with periods of apnea c. Shallow and slow breathing d. Deep breathing with snoring

Sample Question Answer c. Correct. Hypopnea is shallow and slow breathing.

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Sample Question A 23-year-old male is in the ED for contusions sustained from a fall while pruning a tree. He is receiving 40% oxygen by air-entrainment mask. Upon inspection, it is noticed that the patient’s right chest sinks in during inspiration while the rest of the chest rises. This type of breathing pattern would be referred to as which of the following? a. Kussmaul’s b. Paradoxical c. Cheyne-Stoke’s d. Pneumonic

Sample Question Answers

b. Correct- affected area moves in with inspiration opposite to the rest of the lung

a. Not correct- fast, deep breathing c. Incorrect- Increased and decreased breathing rate and

volume, periods of apnea d. Incorrect- no such breathing pattern

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Inspection of Extremities • Digital Clubbing

Manifestation of chronic cardiopulmonary disease seen in Cystic Fibrosis, bronchiectasis, COPD Enlargement of the phalanges of the fingers and toes Angle of the nail advances past 180 degrees

• Edema Soft-tissue swelling. Pitting edema is present. Localized or generalized (anasarca) Associated with kidney, liver, cardiac, pulmonary disease, and venous or lymphatic drainage obstruction Unilateral peripheral edema- may be from venous obstruction

Inspection of Extremities • Bilateral peripheral (dependent) edema

Cause: Cor pulmonale - right heart failure • Progression: feet and ankles = abdominal organs = hepatomegaly

= jugular vein distension • Pitting edema scale

Normal: Pitting returns rapidly Severe: >2 minutes

•  1+ trace (around ankles) to 4+ severe (well above knee)

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Inspection of Extremities • Capillary Refill – commonly performed before obtaining an arterial

blood gas Assessment to determine blood flow to extremities

Blanch extremity

Refill time < 3 seconds

Normal

Refill time > 3 seconds

Reduced cardiac output, dehydration

Inspection of Airway • Macroglossia- unusual enlargement (hypertrophy) of the tongue

Small oral airway- greater potential for obstruction Problems with swallowing and sleeping (obstructive sleep apnea)

• Neck Range of Motion Active- patient able to touch chin to chest Passive- therapist moves the patient’s head Flexibility may be assessed for potential problems with intubation

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Inspection of Airway - Mallampati Scoring -Difficult Intubation

•  No difficulty •  Moderate

difficulty •  Soft palate and

partial uvula visible

•  No difficulty •  Very difficult-only hard palate visible

Grade IV Grade I

Grade II Grade III

Cough and Sputum Inspection •  Cough description-

Effective, productive-mucus producing Inadequate-no mucus, weak, clearing throat

Vital capacity less than normal (< 10-15 mL/kg of IBW) Dry-could be effective or ineffective but no mucus production

•  Directed cough-full, deep cough, against closed glottis •  Huff cough-slow, deep breath, open glottis, quick exhalation •  Recurrent (children)-allergies, asthma •  Dry-infection (viral) •  Dry (initially) then becomes productive-smoking, emphysema •  Chronic and very productive-bronchiectasis •  Stridor-croup, epiglottitis •  Wheezy-asthma •  Paroxysmal (often at night) asthma, left heart failure •  Barking-croup

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Appearance and Cause-Sputum

•  Pulmonary edema •  Lung cancer •  Tuberculosis •  Trauma

•  Smoke inhalation or cigarette smoker

•  Emphysema •  Infection, pneumonia •  Infection, pneumonia,

CF •  Bronchiectasis

Mucoid Purulent

Mucopurulent Foul odor and

layered

Black or Brown

Frothy white or pink

Blood Streaked,

hemoptysis

Cough and Sputum Inspection

HEMOPTYSIS

LUNG BRIGHT RED BLOOD

HEMATAMESIS

STOMACH DARK, GROUND COFFEE

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Cough and Sputum Inspection

TYPES OF COUGH

ACUTE < 3 weeks

Common Cold

SUBACUTE 3-8 weeks

Respiratory Tract Infection CHRONIC

> 8 WEEKS Asthma GERD

Inspection of Newborn-APGAR Score SIGN 0 SCORE 1 SCORE 2 SCORE

A APPEARANCE- COLOR PALE, BLUE ACROCYANOSIS PINK

P PULSE-HEART- RATE ABSENT <100 >100

G GRIMACE- REFLEX NO RESPONSE GRIMACE COUGH, SNEEZE

A ACTIVITY- MUSCLE TONE FLACCID SOME FLEXION WELL FLEXED

R RESPIRATIONS- EFFORT ABSENT WEAK, IRREGULAR GOOD CRYING

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APGAR Score • Purpose

•  Determine quickly whether a newborn needs immediate medical care •  Continue scoring until a 7 score is obtained

1 and 5 minutes following birth

Score 7-10 Normal

Score 4-6 Fairly Low

Score < 3 Critically Low

Sample Question A 37-week gestational age newborn has just been born and the following APGAR score has been obtained:

Appearance/color: Acrocyanosis Pulse: 147/min Grimace reflex: Good cough Activity-Muscle tone: Some Flexion Respirations: Weak, irregular

Based on this finding you would recommend an APGAR score of: a. 9 b. 8 c. 7 d. 5

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Sample Question Answer c. Correct: Score of 7

Appearance/color: Acrocyanosis – 1 point Pulse: 147/min – 2 points Grimace reflex: Good cough – 2 points Activity-Muscle tone: Some Flexion – 1 point Respirations: Weak, irregular – 1 point

Gestational Age Assessment

GESTATIONAL AGE

ASSESSMENT

Maternal Dates

Fetal Ultrasound

Ballard Scoring

Dubowitz Scoring

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Inspection of Newborn Chest

Transillumination of Chest

Normal Findings: Halo appearance on chest

Abnormal Findings: Area under light “lights up” from air or fluid

References Clinical Assessment in Respiratory Care, Sixth Edition, Robert L. Wilkins, James R.

Dexter, Albert J. Heuer, (2009), The Mosby/Elsevier Company, St. Louis, MO. Egan’s Fundamentals of Respiratory Care, Ninth Edition, Robert L. Wilkins, James K.

Stoller, Robert M. Kacmarek, (2009), Mosby/Elsevier Company, St. Louis, MO Respiratory Care Principles and Practice, Second Edition, Dean R. Hess, Neil R.

MacIntyre, Shelley C. Mishoe, William F. Galvin, Alexander B. Adams, (2011), Jones and Bartlett Learning, Sudbury, MA

The Essentials of Respiratory Care. Robert M. Kacmarek, Steven Dimas, Craig W. Mack (2005). Fourth Edition. Mosby/Elsevier, St. Louis, MO

Perinatal and Pediatric Respiratory Care. Brian K. Walsh, Michael P Czervinske, Robert M. DiBlasi (2010). Saunders Elsevier, St. Louis, MO