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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. 2
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.
3Copyright © 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.
4Copyright © 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
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Interviewing
Purposes Establish rapport with patient Obtain essential diagnostic information Help monitor changes in patient’s symptoms &
response to therapy
6Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
7Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
All of the following are reasons why a clinician should review a patient’s medical history and perform a physical examination, except:
A.Helps identify the need for subsequent diagnostic testsB.Helps select the best approach for therapyC.Helps monitor patient’s progress toward predefined goalsD.Determines how long the patient will remain in the hospital
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
8Copyright © 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?
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Cardiopulmonary Symptoms
DyspneaSensation of breathing discomfort by patient
(subjective feeling)Most important symptom RT is called upon to
assess & treat
BreathlessnessSensation of unpleasant urge to breatheCan be triggered by acute hypercapnia, acidosis &
hypoxemia
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Cardiopulmonary Symptoms
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Cardiopulmonary Symptoms
DyspneaSubjective experience. Should not be inferred from
observing patient`s breathing patternOrthopnea: dyspnea in reclining position;
associated w/ CHFPlatypnea: dyspnea in upright position associated
w/ arteriovenous malformationDegree of dyspnea is evaluated by asking about
level of exertion at which it occurs
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Cardiopulmonary Symptoms (cont.)
Language of DyspneaAsk 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
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Cardiopulmonary Symptoms (cont.)
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
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Cardiopulmonary Symptoms (cont.)
Psychogenic Dyspnea: Panic Disorders & HyperventilationPatients have normal cardiopulmonary function of
intense dyspnea & suffocationMay coincide w/ symptoms, such as chest pain,
anxiety, palpitation & paresthesiaAnxiety often accompanied by breathlessness &
hyperventilation
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16Copyright © 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?
A.Platypnea
B.Orthopnea
C.Apnea
D.Eupnea
Cardiopulmonary Symptoms (cont.)
CoughCough 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
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All of the following are common causes of a weak cough effort, except:
A.steroid administration
B.high airway resistance (Raw)
C.weak respiratory muscles
D.poor lung recoil
Cardiopulmonary Symptoms (cont.)
Sputum productionMucus 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
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Cardiopulmonary Symptoms (cont.)
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
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Cardiopulmonary Symptoms (cont.)
Chest painPleuritic 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)
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Cardiopulmonary Symptoms (cont.)
FeverElevation of body temperature due to diseaseMay 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
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Cardiopulmonary Symptoms (cont.)
Pedal edema Swelling of lower extremities - most often due to
heart failure 2 subtypes;
1. Pitting edema—indentation mark left on skin after applied pressure
2. 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
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24Copyright © 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:
A.Pneumonia
B.Pulmonary Embolism
C.Costochondritis
D.Pneumothorax
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
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Medical History (cont.)
RT’s priority—ensure all respiratory care procedures are supported by physician order (current, clearly written & complete)
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27Copyright © 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?
A.10 pack-year
B.20 pack-year
C.30 pack-year
D.40 pack-year
Physical Examination
Essential for evaluating patient’s problem & determining ongoing effects of therapy
Consists of 4 steps:1. Inspection (visually examining)
2. Palpation (touching)
3. Percussion (tapping)
4. Auscultation (listening with stethoscope)
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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
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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)
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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
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Vital Signs (VS)
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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
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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:
A.Hypothermic
B.Febrile
C.Confused
D.Emaciated
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
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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
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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
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Head & Neck Exam
HeadAbnormal signs help indicate respiratory problemsNasal flaring: often seen in infants w/ respiratory
distress—increased WOBCyanosis 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
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Head & Neck Exam (cont.)
NeckTrachea should be midline;may shift away from
midline in certain thoracic disordersJugular venous distention (JVD) is seen in patients
w/ CHF & cor pulmonaleEnlarged lymph nodes in neck may occur w/
infection or malignancy
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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:
A.right heart failure
B.cardiac tamponade
C.cor pulmonale
D.pulmonary hypertension
Examination of Thorax
Barrel chest—seen w/ emphysema; indicates poor lung recoil
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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
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Examination of Thorax (cont.)
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Breathing Pattern
Abnormal breathing pattern—broken into 2 broad categories:1. Associated w/ thoracic or pulmonary disease that
increases WOB (asthma)
2. Associated w/ neurologic disease (central sleep apnea)
Rapid & shallow breathing is consistent w/ restrictive lung diseases
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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)
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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
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All of these are common causes of an abnormal breathing pattern associated with thoracic or pulmonary disease that increases work of breathing, except:
A.Central sleep apnea
B.COPD
C.Asthma
D.Pulmonary edema
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
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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)
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Chest Auscultation
Lung sounds come in 2 varieties1. Breath sounds
2. Adventitious lung sounds Breath sounds = normal sounds of breathing Adventitious lung sounds = abnormal sounds
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Breathing Pattern
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Chest Percussion
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Chest Auscultation (cont.)
Breath soundsTracheal 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
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Chest Auscultation (cont.)
Breath soundsReduced 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
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Chest Auscultation (cont.)
Adventitious lung sounds 2 varieties:
1. Discontinuous• Intermittent crackling
• Bubbling sounds of short duration
• Referred to as “crackles”
2. Continuous• Referred to as “wheezes”
• Heard over the upper airway is called “stridor”
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Chest Auscultation (cont.)
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)
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Chest Auscultation (cont.)
Wheezes are Consistent w/ airway obstruction Monophonic wheezing indicates one airway is
affected Polyphonic wheezing indicates many airways are
involved
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Chest Auscultation (cont.)
Stridor Upper airway compromised Chronic stridor—laryngomalacia Acute stridor—croup Inspiratory stridor—narrowing above glottis Expiratory stridor—narrowing of lower trachea
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Chest Auscultation (cont.)
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
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Chest Auscultation (cont.)
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What condition may cause an RT to hear sudden high-pitched popping noises during the late-inspiration phase?
A.Atelectasis
B.Asthma
C.Croup
D.Bronchitis
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)
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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
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Cardiac Examination (cont.)
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
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Cardiac Examination (cont.)
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
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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.
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Examination of Extremities
Digital clubbing (not common) - seen in large variety of chronic conditions: congenital heart disease, bronchiectasis, various cancers, & interstitial lung diseases
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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
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