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RTH 112

Assessment

Unit 2

Text Reference

• Egan 9th Edition– Chapter 15 “Bedside Assessment of the

Patient”

Objectives• Write a brief summary explaining the importance

of conducting a patient interview in 500 words or less

• Without the use references, list the major components of a health history

• Using the notes, review the techniques to conduct a patient interview

• Without the use of references, summarize the importance of conducting a physical examination

• Verbally describe the four major examination techniques

Patient Evaluation

• Initial Assessment– Clinical Manifestations

• Patient Interview

• Physical Examination

• Secondary Assessment– Diagnostic Studies

• Arterial Blood Gases

• Pulmonary Function Studies

• Chest Films

• Other Diagnostic Procedures as Indicated

Patient Interview

• Determine Level of Consciousness– Normal: alert & cooperative– Lethargic– Confused– Obtunded: diminished cough or gag– Semi-comatose: responds to painful stimuli– Coma: unresponsive to pain

Patient Interview

• Orientation of time, place and person– Well oriented, cooperative

• Able to follow simple commands

– Disoriented, confused– Inability to cooperate:

• Language difficulties• Influence of medications• Hearing loss• Fear, depression

Patient Interview• Assess Emotional State

– Anxiety• Respiratory distress, hypoxemia

– Depression• Quiet or withdrawn, in denial

– Anger• Combative, irritable

– Euphoria• Influence of drugs

– Panic• Hypoxia, air hunger, status asthmaticus

Patient Interview• Measure Subjective Symptoms

– Orthopnea• Difficulty breathing except in upright position

– General Malaise• Run down, nausea, weakness, fatigue

– Dyspnea• Feeling SOB

– Grade I: normal dyspnea after unusual tension– Grade II: breathless after going up hill or stairs– Grade III: dyspnea while walking at normal speed– Grade IV: dyspnea moving slowly & short distances– Grade V: dyspnea at rest, small tasks

Patient Interview

• Pain– Location

– Quality (what kind is it)

– Severity

– Aggravating factors

– Relieving factors

– History (when did it start and how did it progress)

– Context (circumstances of onset)

– Accompanying Symptoms

Patient Interview

• Symptoms of Nose and Throat– Nasal secretions

• Amount

• Irritants, allergies

– Itching or burning sensation of nose and throat– Dysphagia

• Difficulty swallowing

• Hoarseness

Patient Interview

• History of present illness– Current medical/physical problems– Current meds, including herbs, etc.

• Past medical history– Previous medical problems, hospitalizations,

surgeries, drug allergies, etc

• Family history– Heart disease, diabetes, COPD, etc.

Interview Techniques

• Ask open ended questions– No yes or no questions

• Communicate using simple language– KISS Method– Use pictures, diagrams– Interpreter for those with language barriers

Physical Examination

• Begin with Assessment by Inspection– What Can You See?

Assessment By Inspection

• General Appearance– Age– Height– Weight– Sex– Nourishment


• Peripheral Edema– Presence of excessive fluid in the tissue– Pitting Edema– Occurs primarily in arms and ankles– Caused by CHF, Renal insufficiency/failure– Rated +1, +2, +3

• The higher the number, the greater the swelling

Peripheral Edema

Abnormal buildup of fluid in the ankles, feet, and legs is called peripheral edema. Foot with Edmea Normal Foot


• Clubbing of fingers– Suggestive of pulmonary disease– Caused by chronic hypoxia– Can affect thumb, fingers and toes– Condition is present when the angle of the nail

bed and skin increases


• Venous Distention– Occurs with CHF– Seen in patients with obstructive lung disease– Seen during exhalation because of the

obstructive component


• Capillary Refill– Quick check of perfusion– Blanching of hand or nail beds and watch for

blood return– Normally 3-5 seconds– Commonly performed for the Allen’s Test

before arterial blood gas puncture


• Diaphoresis– State of perfuse/heavy sweating– Heart failure– Fever, infection– Anxiety, nervousness– Tuberculosis (night sweats)


• Skin Color– Normal: pink– Abnormal: pale

• Due to anemia or blood loss

– Jaundice: yellow• Increase in bilirubin, mostly face & trunk

– Erythema: redness• Capillary congestion, inflammation, infection

– Cyanosis: blue/gray• Hypoxia (5 g of reduced hemoglobin)

Assessment By Inspection• Chest Configuration

– Normal: A-P diameter• Straight spine, no alterations in chest size

– Pectus Carinatum• Anterior protrusion of the sternum

– Pectus Excavatum• Depression of the sternum

– Kyphosis• Hunchback or convex spine curve

– Scoliosis• Lateral curve of the spine

– Kyphoscoliosis: combination of both– Barrel Chest

• Increased A-P diameter resulting form air trapping


• Movement of Chest/Diaphragm– Symmetrical movement– Unequal movement

• Chronic lung disease

• Atelectasis

• Pneumothorax

• Flail Chest – paradoxical

• Intubated with ET tube in one lung

Assessment By Inspection• Breathing Patterns

– Eupnea – normal rate, depth, rhythm– Tachypnea- over 20 bpm

• Fever, hypoxia, pain, CNS problem

– Bradypnea- less than 8 bpm• Variable depth and irregular rhythm

– Apnea- cessation of breathing– Hyperpnea- increased rate & depth, regular

rhythm• Metabolic/CNS disorders


• Breathing Patterns– Cheyne Stokes- gradual increasing the decreasing rate

and depth in a cycle with periods of apnea• Increased ICP, Meningitis, overdose

– Biots- increased rate and depth with irregular periods of apnea

• CNS problem

– Kussmauls- increased rate (>20) increased depth, irregular rhythm, seems labored

• Metabolic acidosis, renal failure, diabetic ketoacidosis


• Breathing Patterns– Apneustic- prolonged gasping inspiration

followed by extremely short, insufficient expiration

• Problem with respiratory centers, trauma or tumor


• Muscle use– These muscles are used to increase ventilation

during times of stress, increased airway resistance, etc.


• Muscle Use

Muscles used during Normal Breathing – Diaphragm– External Intercostals– Exhalation is passive


• Accessory Muscle Use– Used to increase ventilation

Muscles of normal ventilation PLUS• Intercostals, scalene, sternocleidomastoid, PLUS

• Abdominal muscles

Assessment By Inspection• Retractions

– Chest moves inward during inspiration instead of outward

– Due to a blocked (obstructed airway)

– A sign of respiratory distress in infants

• Nasal Flaring– Flaring of the nostrils during inspiration

– A sign of respiratory distress in infants sometimes accompanied by grunting


• Character of Cough– Strong, moderate, weak– Productive, nonproductive– Frequent, infrequent– Tight, moist

Assessment By Palpation

• Pulse– Normal: 60-100– Tachycardia: >100– Bradycardia: <60– Adverse Reaction: >20 Increased HR– Monitor rhythm


• Tracheal Deviation– Pulled toward pathology (inside lung)

• Atelectasis

• Pneumonectomy

• Diaphragmatic paralysis

– Pulled away from pathology (outside lung)• Massive pleural effusion

• Tension Pneumothorax

• Neck or thyroid mass

• Large mediastinal mass


• Tactile Fremitus– Vibration felt by hand on the chest wall

• Vocal fremitus-voice vibrations on the chest wall

• Pleural rub fremitus – grating sensation due to roughened pleural surfaces rubbing together

• Rhonchial fremitus – secretions in the airway


• Tenderness– Around suture sites, chest tubes, fractures

– Avoid areas of tenderness if possible


• Chest Motion Symmetry– Hands placed on the patient’s chest move in

symmetry. If one hand moves more than the other, it indicates asymmetrical chest expansion

Assessment By Percussion

• Performed by placing the middle finger between two ribs and tapping the middle finger’s first joint with the middle fingers of the opposite hand.– Resonance- normal air filled lung; hollow sound– Flat- over sternum, muscle or atelectasis; full sound– Dull-fluid filled organs; pleural effusion or pneumonia;

thudding sound– Tympany-air filled stomach; drum like sound– Hyperresonance-Areas of the lung with pneumothorax

or emphysema. Booming sound.

Assessment By Auscultation

• Normal Breath Sounds- vesicular

– Bilateral vesicular: normal in both lungs– Bronchial vesicular: normal over the trachea or

bronchi

Assessment By Auscultation• Increased, decreased, unequal or absent

– Always compare one lung with the other

– Egophany: “E” sound like “A”. Consolidation– Bronchophony & whispered pectoriloquy: increased

intensity of voice when spoken. Indicated consolidation and pneumonia

– An increase in voice indicates consolidation and pneumonia

– A decrease in voice indicates obstructed bronchi, pneumothorax, emphysema


• Abnormal Breath Sounds – adventitious– Rales (crackles)- fluid/secretions

• Coarse (rhonchi)- large airway secretions– Suction the pt/cough

• Medium– Pt needs CPT

• Fine (moist crepitant rales)- alveoli fluid– Pt has CHF/pulmonary edema

– PT needs IPPB, heart drugs, diuretics and oxygen


• Wheezes– Bronchospasm– Patient needs a bronchodilator– Unilateral wheezes indicative of FBO


• Stridor– Upper Airway Obstruction

• Supraglottic swelling (epiglottitis)• Subglottic swelling (croup, post extubation)• Foreign body aspiration

– Treatment• Topical decongestant (racemic epinephrine)• Suction/bronchoscopy • Intubation for severe swelling and epiglottitis


• Pleural Friction Rub– Caused by infection – A coarse grating or crunching sound– Inflamed visceral and parietal pleural surfaces

rubbing together– Associated with pleurisy, TB, pneumonia,

cancer, etc.– Treat with steroids, antibiotics as indicated

Breath Sounds Review

http://Breath Sounds Review

http://www.wilkes.med.ucla.edu/lungintro.htm

http://www.wilkes.med.ucla.edu/lungintro.htm

Reference Link

• The Lung Exam

http://medicine.ucsd.edu/clinicalmed/lung.htm

Health & Medicine

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