Patient Assessment Reviewed ed

How can assessment skills help me professionally?

• professional security

• professional advancement

• professional respect ( etiquette)

What are several specific steps that must be effectively gathered?

1. review patients chart

2. patient interview

3. physical examination

The Chart Review…

• must be done prior to entering a patients room

• must identify the reason for patient admission

• must identify the type of therapy a patient is to receive

What does a chart provide?

• patient history

• family history

• social history

What are the three goals that provide the patients perspective on their illness?

• establish rapport

• obtain essential diagnostic information

• monitor changes in patient symptoms and response to the therapy

What are the guidelines for effective patient interviewing?

• project a sense of undivided interest in patient

• establish your professional role

• be respectful of patients beliefs, attitudes and rights

• use a relaxed, conversational style

• provide a comfortable setting ( when possible)

The interviewer can ask the patient?

1. open ended questions

2. closed ended questions

If the patient has a cough, what are appropriate questions to ask?

• length of time

• strong or weak

• loose or dry

• productive or nonproductive

If the patient has sputum production what are appropriate questions to ask?

• quantity

• consistency

• color

If the patient has hemoptysis what questions is it appropriate to ask?

massive vs non massive

Hemoptysis

coughing up blood

Hematemesis

vomiting blood

During patient interview check/ask for

• jugular vein distention

• dyspnea

• chest pain

• cyanosis

• digital clubbing

• wheezing or stridor

• level of consciousness

Orthopnea

shortness of breath while laying flat

Platypnea

shortness of breath while sitting up

What are the levels of consciousness?

• Confused

• Delirious

• lethargic

• obtunded

• stuporous

• comatose

Confused

slight decrease in consciousness,incoherent thoughts,slow mental response

Delirious

easily agitated,irritable and hallucinations

Lethargic

sleepy,arouses easily, responds appropriately when aroused

Obtunded

awakens only with difficulty, responds appropriately when aroused

Stuporous

does not awaken completely, decreased mental and physical activity, responds to pain,repsonds slowly to verbal stimuli

Comatose

unconscious, does not respond to stimuli, does not move voluntarily, signs of upper motor neuron dysfunction

Vital signs

• body temp

• pulse rate

• resp rate

• blood pressure

Hyperthermia causes?

O2 consumption and CO2 production to increase 10% per 1c increase

Hypothermia causes?

O2 consumption and Co2 production to decrease 10% per 1c decreases

IPPA

• inspection

• palpation

• percussion

• auscultation

What is inspection?

The observation of the patient ( visual)

What are some examples of what to look for during inspection?

• chest symmetry

• paradoxical chest abdominal movement

• jugular vein distention JVD

• pedal edema

• pursed lip breathing

• nasal flaring

• retractions

• cyanosis

• digital clubbing

• level of consciousness

• cough

• sputum

• anatomical abnormalities

• accessory muscle use

• respiratory rate and pattern

What is the normal anterior-posterior to lateral AP diameter?

1:2

What does barrel chest result from?

chronic hyperinflation

What is the barrel chest A-P diameter?

1:1

What bony deformities to look for?

• kyphosis

• scoliosis

• kyphosis-scoliosis

• lordosis

• pectus carinatum

• pectus excavatum

Kyphosis

bent forward

Scoliosis

lateral curvature

Kyphoscolisosis

combination to kyphosis and scoliosis

lordosis

backward curvature of spine resulting in a sway back appearance

pectus carinatum

protrusion of sternum anteriorly

pectus excavatum

depression of the sternum

What is palpation?

the touching of the chest to evaluate movement and underlying lung function

What to look for when palpataing ?

• chest symmetry

• subcutaneous emphysema

• tone of ventilatory msucles

• tracheal shift

• fremitus

What is fremitus?

the vibration produced over the thoracic cage by the conduction of sound waves

Tactile Fremitus

• vibrations that can be felt over the chest during breathing

• vibrations caused by gas flowing through thick secretions that are obstructing the large airways

• performed bilaterally on the chest to compare sides

• normally it is equal throughout all lung fields

Vocal fremitus

• vibrations that can be felt over the chet during phonation

• ask the patient to say “99” “blue moon” while palpating thorax

Increased tactile and vocal fremitus

( increased intensity of vibration)

• increased lung tissue density

• diseases of hypoinflation, loss/decrease in ventilation in the lungs

where can we see examples of increased tactile and vocal fremitus?

• pneumonia

• consolidations

• atelectasis

Decreased tactile and vocal fremitus

( decreased intensity or absence of vibration)

• decreased lung tissue density

• diseases of hyperinflation

Examples of where we can see decreased tactile and vocal fremitus

• COPD

• Asthma

• pneumothorax

Percussion

• production of audible ( sound ) vibrations over the chest by tapping the chest wall

• performed bilaterally, both anteriorly and posteriorly to compare

Increased percussion

is a hyperresonant or tympanic sound

• drum like

• decreased lung tissue density

• diseases of hyperinflation

• excess air in thorax

examples of increased percussion

• COPD

• asthma

• pneumothorax

Decreased percussion

• dull sound

• increased lung tissue density

• diseases

Examples of decreased percussion

• pneumonia

• consolidations

• atelectasis

Auscultation

listening to the chest provides information

What kind of information does listening to the chest provide?

• heart

• blood vessels

• air flowing in and out of tracheobronchial tree and alveoli

The stethoscope is used to evaluate sounds:

• frequency

• intensity

• duration

• quality

Auscultation is performed to compare?

anterior and posterior

Normal breath sounds

• bronchial ( tracheal)

• bronchovesicular

• vesicular

Bronchial ( tracheal) breath sounds

• heard over the trachea

• loud and tubular

• inspiratory and expiratory

Bronchovesicular

• heard over the airways

• softer than bronchial breath sounds and lower in pitch

• inspiratory and expiratory

Vesicular

• soft muffled sound

• heard over lung parenchyma

• heard usually on inspiration and minimally during exhalation

Adventitious breath sounds

• abnormal breath sounds are adventitious

• breath sounds that are not normally heard in a healthy lung

• may include normal breath sounds heard over an abnormal area of the lungs

Crackles ( rales)

• discontinuous sound

• inspiratory and or expiratory

• fine and or coarse

crackles are heard when

secretions in small airways,pulmonary edema, CHF, ARDS, opening and closing of collapsed airways heard at end inspiration and or end expiration ( atelectasis)

Rhonchi

• continous sound

• louder,low pitched gurgling

Examples of rhonchi

indicative or excessive secretions in large airways

Wheezes

• high pitched or low pitched whistling sound

• inspiratory and or expiratory

indications of wheezes

• bronchospasm, mucosal edema in medium to larger airways, asthma

Pleural friction rub

• raspy creaking or grating sound

examples of pleural friction rub

• inflamed plural surfaces rubbing together

Diminished breath sounds

• descriptive

• quiet or distant

What does diminished breath sounds indicate

• indicates decreased ventilation ( air movement) or alveolar hypoventilation

Terms used to describe vocal resonance

bronchophony and whispered pectoriloquy

vocal resonance

unusually clear transmission of whispered or spoken voice when auscultating chest w a sethoscope

Vocal resonance is

normally diminished or unintelligible- sound disperses throughout large surface area of alveoli which reduces sound transmission

Vocal resonance will be increased ( louder)

• over areas of consolidation, atelectasis, etc

• usually accompanies a dull percussion note and increased tactile and vocal fremitus

Vocal resonance will be decreased ( quieter)

• air trapping,hyperinflation, pneumothorax

• usually accompanied by diminished breath sounds and decreased tactile and vocal fremitus

Egophony

ask the patient to say E continuously

Hearing a nasal sounding “A” indicates

egophony is present ( increased)

• auscultate bilaterally, anteriorly and posteriorly

When does egophony increase?

increases with pneumonia, consolidations, pleural effusion and fibrosis