Egan's Chapter 16: Bedside Assessment of the Patient

INTERVIEWING

Provides unique information because it represents the patient's perspective, and serves the following purposes

• Establish a rapport between clinician and patient

• Obtain info. essential for making a diagnosis

• Help monitor changes in patient's symptoms and response to therapy

It also projects a sense of undivided interest in the patient, establishes a professional role, and shows respect for the patient's beliefs, attitudes, and rights.

social space

is 4-12 feet from the patient which is considered "socially appropriate" between strangers and is perceived as non-threatening. This should be done in the beginning of the interview during introductions. "Appropriate" space varies based on cultural differences and backgrounds.

personal space

2-4 feet from the patient. Done after introduction is made and at the beginning of the interview. It allows the interview to occur with a normal or soft speaking voice and creates a sense of intimacy needed for disclosing personal information. Creating a comfortable rapport is an important part of RT and patient relationship.

PRINCIPLES OF INTERVIEWING

• Factors affecting communication between RT and patient include:

- Sensory and emotional factors

- Environmental factors

- Verbal and nonverbal components of communication

- Cultural and other internal values, beliefs, feelings, habits, and preoccupations of both the RT and patient

Signs

refer to the objective manifestation of illness (e.g., increased respiratory rate and heart murmur)

Symptoms

refer the sensation or subjective experience of some aspect of an illness

- Must always be stated by the patient and never inferred

- Examples: breathlessness, cough

5 NEUTRAL QUESTIONS TO ASK FOR EACH SYMPTOM

• When did the symptom start?

• How severe is it? (Scale of 1 - 10.)

• Where on the body is it?

• What seems to make it better or worse?

• Has it occurred before? (If so, how long did it last?)

Dyspnea

Ø Sensation of breathing discomfort by patient (subjective feeling)

Ø Most important symptom RT is called upon to assess and treat

Ø A subjective experience (cannot be inferred from observing patients breathing pattern)

Ø Difficulty in the mechanical act of breathing

causes of dyspnea

upper or lower airway infection

acute pulmonary edema

chronic obstructive pulmonary disease (COPD)

asthma

hay fever

anaphylaxis

spontaneous pneumothorax

pleural effusion

prolonged seizures

obstruction of airway

pulmonary embolism

hyperventilation syndrome

environmental exposure

carbon monoxide poisoning

infectious diseases

orthopnea

dyspnea triggered by reclining

Platypnea

dyspnea triggered by assuming the upright position

Trepopnea

dyspnea that occurs when a patient with unilateral lung disease lies with the affected side in the down position

breathlessness

o An unpleasant urge to breathe

o Triggered by acute hypercapnia, acidosis or hypoxemia

Causes of breathlessness

Anxiety, obstructive or restrictive disorder, neuromuscular disease, medications, nerve compression or damage, stroke, muscular dystrophy, scoliosis, thoracic cage abnormalities, etc.

The three factors that generate the perception of breathing

1. The neural drive to breathe coming from the respiratory centers in the brainstem

2. The tension developed in the respiratory muscles

3. The corresponding displacement of the lungs and chest wall

List the four interview questions used to assess the degree and context of dyspnea in patients.

● What activities of daily life trigger dyspnea? For example: climbing stairs, bathing

● How much exertion makes the patient stop to catch his or her breath with different activities? Example: does the patient need to stop after walking up one flight of stairs?

● Does the quality of dyspnea vary by the type of activity?

● When did dyspnea first become a common feature of your life? How has it evolved over time?

Recall the four factors necessary to generate an effective cough.

● The ability to take a deep breath

● Lung elastic recoil

● Expiratory muscle strength

● Level of airway resistance

Identify five important cough characteristics that the RT is responsible for monitoring.

● Whether the cough is dry or loose

● Productive or nonproductive (of sputum)

● Acute or chronic

● Occurs more frequently at particular times

● Whether it is provoked by a particular position

If the trachea is not midline

Trachea can shift away from midline and towards an area of collapsed lung and away from areas with increased air or fluid

Kussmaul sign

Jugular venous pressure increases during inhalation

Jugular Venous Distention

▪ Present when the jugular vein is enlarged and can be seen more than 4 cm above the sternal angle

▪ Common in patients with chronic hypoxemia

barrel chest

abnormal increase in AP diameter

▪ Associated with emphysema

reduced chest expansion

Causes include COPD, pleural effusion and pneumothorax

retractions

Inward movement of the chest wall with inspiration; usually a sign of respiratory distress. 3 types:

▪ Intercostal

▪ Subcostal

▪ Supraclavicular

tracheal tugging

another form of retraction

▪ downward movement of the thyroid cartilage toward the chest during inspiration in concert with sternocleidomastoid muscle recruitment

Sputum production

Airway disease may cause mucous glands in the airways to produce abnormal amounts of mucus. This stimulates the cough receptors and causes a loose, productive cough

SPUTUM PRODUCTION: Phlegm

Mucus from tracheobronchial tree not contaminated by oral secretion

SPUTUM PRODUCTION: Sputum

Mucus from lower airways but is expectorated through mouth

- Recent changes in sputum color, viscosity, or quantity may indicate infection

SPUTUM PRODUCTION: Purulent

Sputum having pus cells

SPUTUM PRODUCTION: Fetid

Foul-smelling sputum

SPUTUM PRODUCTION: Mucoid

Clear, thick sputum commonly seen in patients with asthma

hemoptysis

coughing up blood or blood-streaked sputum from the lungs is common in patients with pulmonary disease

HEMOPTYSIS: Massive

Ø A medical emergency defined by coughing a variable volume of blood over a defined time period

Ø More than 300 ml of blood expectorated over 24 hours

Ø Common causes: bronchiectasis, lung abscess, and acute or chronic tuberculosis

Ø Distinguished from hematemesis (vomiting blood from gastrointestinal tract)

HEMOPTYSIS: Nonmassive

Ø Common causes include: infection of airway, pneumonia, lung cancer, tuberculosis, trauma, and pulmonary embolism

Ø Infection-associated hemoptysis usually presents as blood streaked, purulent sputum

Ø Hemoptysis from bronchogenic carcinoma often is chronic and maybe associated with a monophonic wheeze and cough

hematemesis

Blood vomited from the gastrointestinal tract

Often occurs in patients with gastrointestinal disease

Vomiting can stimulate the cough reflex

Ø Sometimes difficult to differentiate the origin of bleeding

This blood may be mixed with food particles and have an acidic pH

pleuritic chest pain

located laterally or posteriorly - described as sharp and stabbing pain, & worsens when breathing (pneumonia, emphysema, pleural effusion, & pulmonary embolism), Associated with diseases that cause pleural lining to become inflamed

Nonpleuritic chest pain

is dull ache or pressure located in center of the anterior chest & may radiate to shoulder or arm

Common Symptom:

*Exertion, Stress and is associated with coronary occlusion (not affected by breathing)

fever

Elevation of body temperature due to disease (greater than 38.3°C; 101°F)

● Associated with:

● Bacterial

● Viral

● Fungal Infections

non-infectious

*Drug Reactions

*Malignancies

*Head Trauma

*Burns

*Alcoholic Cirrhosis

*Hypothermia

*Thromboembolic Disorder

PEDAL EDEMA

-Swelling of lower extremities—most often due to heart failure

-Characteristic: finding CHF, for pulmonale, End-stage liver disease

pitting edema

indentation left after examiner depresses the skin over swollen edematous tissue

Weeping edema

small fluid leak occurs at point where pressure applied

five major categories of patient information gleaned from reviewing the medical record

1. Chief complaint (CC)/ history of present illness (HPI)

- Explains current medical problems

2. History if Patient Illness

Past medical history (PMH)-

3. Smoking history is often recorded in pack-years

- Packs smoked per day × number of years smoked

4. Family/Social/Environmental history

- Potential genetic or occupational links to disease and patient's current life situation

5. Review of systems (ROS)

* Advance directive (not major but still should be included)

- Living will or personal directive

There are 20 cigarettes per pack. If a patient states he or she has smoked a pack and a half of cigarettes per day for 20 years, the smoking history is calculated as follows:

30 cigarettes/20 cigarettes per pack= 1.5 packs x 20 years= 30 pack years smoking history

If the patient states that he or she has smoked 15 cigarettes per day for 20 years:

15 cigarettes/20 cigarettes per pack= 0.75 packs x 20 years= 15 pack years smoking history

Four general steps taken during the physical examination of a patient.

*Visual Inspection

*Palpation

*Percussion

*Auscultation

Causes of slow respiratory rate

trauma, hypothermia, drugs

causes of rapid respiratory rate

anxiety, stress, running adrenaline, drugs

sensorium

referring to a patient's consciousness

four criteria used to determine sensorium

the patient's orientation to time, place, self and their current circumstances

Basic Vital Signs

*Temperature- 98.6

*Pulse Rate-60 to 100 beats/min

*Blood Pressure- systolic 90 to 140mm diastolic 60 to 90mm

*Respiratory Rate- 12 to 20 breaths/min

*Oxygen Saturation- 95 to 100

Seven anatomic sites where a pulse pressure can be palpated during a physical exam.

*Radial

*Brachial

*Femoral

*Carotid

*Dorsalis pedis

*Popliteal

*Posterior Tibial Arteries

*Temporal

Hypertension

is arterial blood pressure PERSISTENTLY greater than 140/90mm. (Constriction or Stiffening of blood vessels) Can cause CNS abnormalities like headaches, blurred vision and confusion

three categories to describe hypertension

Stage 1: systolic pressure of 140 to 159mm Hg or a diastolic pressure of 90 to 99mm Hg.

Stage 2: hypertension occurs with a systolic pressure is 160 mm Hg or greater or a diastolic pressure is 100mm Hg greater.

Stage 3: Prehypertension is used to assess the future risk of developing hypertension. Systolic pressure between 120 and 139mm Hg or diastolic between 80 and 89mm Hg.

the steps required to measure blood pressure using a blood pressure cuff and stethoscope.

Deflated cuff is wrapped around the patient's upper arm with the lower edge of the cuff 1 inch above the arterial vein. The cuff is inflated approx. 30 mm above the point which the pulse is no longer felt. The diaphragm of the stethoscope is placed over the artery and the cuff is slowly deflated while observing the manometer.

The first Korotkoff sounds are heard. The point where the cuff pressure equals diastolic pressure turbulence ceases(disappears) is the second number.

respiratory distress produces common facial signs such as:

nasal flaring, cyanosis, and pursed lip breathing

cyanosis

is bluish discoloration of the skin or oral mucosa resulting from respiratory or cardiac disease

patient with COPD may use

pursed lip breathing during exhalation that creates resistance to flow which creates a slight back pressure in airways that prevents premature airway collapse and allows more complete emptying of lung

inspection/palpation of neck determine position of what?

trachea and jugular venous distention (JVD)

trachea shifts away from areas with what?

increased air or fluid (tension pneumothorax/large pleural effusion)

trachea can shift toward an area of what?

collapsed lung

Jugular Venous Distention (JVD)

-rising typically reflects hearts inability to adequately pump blood

- is common in patients with chronic hypoxemia who develop right heart failure (cor pulmonale) from hypoxia-induced pulmonary hypertension

- conditions also include left heart failure, cardiac tamponade, tension pneumothoraxes, mediastinal tumors

thoracic configuration

-patients with COPD have a premature increase in AP diameter (barrel chest)

-barrel chest is associated with emphysema

thoracic expansion

-diseases that restrict lung expansion also reduce chest expansion on affected side

-causes of reduced expansion include neuromuscular disorders (from muscular weakness), COPD (from lung hyperinflation), lobar consolidation (non-distensible tissue), pleural effusion, and pneumothorax (loss of pleural space integrity to transmit inspiratory muscle pressure

Breathing pattern and effort

-sign of increased WOB is use of accessory muscles

-causes of increased WOB are airway obstruction (COPD, asthma), edematous (heavy) lungs (acute respiratory distress syndrome, cardiogenic pulmonary edema), or stiff chest wall (ascites, anasarca, pleural effusions)

-Increased WOB = visible distortions in chest wall called retractions

Differentiate the two archetypal breathing patterns associated with restrictive versus obstructive lung disease.

1. first is characterized by a rapid, shallow breathing pattern

-occurs in patients with increased lung inflammation or stiffness

--ARDS, pulmonary fibrosis

2. second is characterized by an abnormally prolonged exhalation with pronounced, sustained abdominal muscular contraction

-lower airway obstruction

3. additional pattern is kussmaul breathing which is observed during severe metabolic acidosis- patients breathe rapidly and deeply similar to a normal person during exercise

Kussmaul breathing

-patients breathe rapidly and deeply

-similar to a normal person during strenuous exercise

-metabolic acidosis

Cheyne-Stokes breathing

-respiratory rate and tidal volume gradually increase in intensity then gradually decrease to complete apnea which may last several seconds

-coma from severe cerebral lesions

-metabolic derangements

-low cardiac output states (CHF)

--caused by prolonged blood transit time between the lungs and the medulla where in changes in respiratory center PCO2 lag behind changes in arterial PCO2

-sometimes occurs during sleep in the elderly

Biot breathing

-chaotic breathing pattern

-frequent irregularity in both rate and tidal volume

-occurs with damage to the medulla

agonal breathing

-intermittent prolonged gasps

-caused by preterminal brain stem reflex

apnea

-no breathing

-caused by cardiac arrest, narcotic overdose, severe brain trauma

apneustic breathing

-deep, gasping inspiration with brief, partial expiration

-caused by damage to upper medulla or pons caused by stroke or trauma; sometimes observed with hypoglycemic coma or profound hypoxemia

Ataxic breathing

-completely irregular breathing pattern with variable periods of apnea

-caused by damage to medulla

Asthmatic breathing

-prolonged exhalation with recruitment of abdominal muscles

-obstruction to airflow out of the lungs

central neurogenic hyperventilation

-persistent hyperventilation

-caused by midbrain and upper pons damage associated with head trauma, severe brain hypoxia, or ischemia

Abdominal Paradoxical Breathing

-abdominal wall moves inward on inspiration and outward on expiration

-caused by diaphragmatic fatigue or paradox

chest paradoxical breathing

-part or all of the chest wall moves in with inhalation and out with exhalation

-caused by chest trauma with multiple rib or sternal fractures

periodic breathing

-breathing oscillates between periods of rapid, deep breathing and slow, shallow breathing without prolonged periods of apnea

-same causes as cheyne-stokes

Diaphragmatic fatigue

Found in many types of chronic and acute pulmonary diseases

Signs of acute fatigue

Ø Tachypnea

Ø Diaphragm and rib cage muscles take turns powering breathing (respiratory alternans)

Ø Abdominal paradox occurs with complete diaphragmatic fatigue

Ø Hoover sign

Chest Palpation

Palpation is the art of touching the chest wall to evaluate underlying structure and function

Vocal and tactile fremitus is increased with what?

pneumonia and atelectasis (consolidation)

Vocal and tactile fremitus is reduced with what?

emphysema, pneumothorax, and pleural effusion

bilateral reduction in chest expansion

seen in neuromuscular disorders and COPD

unilateral reduction in chest expansion

consistent with pneumonia or pneumothorax

percussion over lung fields

Performed systematically by consecutively testing comparable areas on both sides of the chest

Resonance of chest evaluated with percussion

Findings should be labeled as "normal," "increased," or "decreased" resonance

Decreased resonance

pneumonia or pleural effusion (consolidation)

Increased resonance

emphysema or pneumothorax (air)

three normal breath sounds

vesicular, bronchovesicular, tracheal

vesicular breath sounds

-low pitch

-soft intensity

-location is the peripheral lung areas

bronchovesicular breath sounds

-moderate pitch

-moderate intensity

-location is around upper part of sternum, between scapular

Tracheal breath sounds

-high pitch

-loud intensity

-location over trachea

crackles (breath sounds)

discontinuous sounds are intermittent, crackling, or bubbling sounds of short duration

fine crackles

high-pitched, discrete, discontinuous crackling sounds heard during the end of inspiration; not cleared by a cough

-caused by excessive fluid secretions in airways

-atelectasis

-fibrosis

-pulmonary edema

coarse crackles

Low-pitched, bubbling or gurgling sounds that start early in inspiration and extend into the first part of expiration

-caused by excessive fluid on the lungs

-severe pneumonia

-bronchitis

wheeze breath sounds

Ø Consistent with airway obstruction

Ø Monophonic wheezing indicates one airway is affected

Ø Polyphonic wheezing indicates many airways are involved

Ø continuous; asthma and CHF

Stridor breath sounds

-heard primarily over larynx and trachea during inhalation

-loud, high-pitched sound associated with upper airway obstruction and often heard without a stethoscope

-laryngomalacia is most common cause of chronic stridor

-croup

-epiglottitis

-postextubation laryngeal edema

-croup is most common cause of acute stridor

inspiratory stridor

narrowing above glottis

expiratory stridor

narrowing of lower trachea

the point of maximal impulse (PMI) and how it is affected in common cardiopulmonary diseases

-left ventricular contraction is most forceful and generates PMI

-cardiopulmonary disease often produces changes in PMI

--PMI shifted laterally with left ventricular hypertrophy

--PMI is often difficult to palpate in severe emphysema, because hyperinflated lungs poorly transmit systolic vibration