Chapter 16: Bedside Assessment of the Patient

Advance directive

set of instructions documenting what treatment a patient would want if they were unable to make medical decisions

Types of advance directives

• DNR - do not resuscitate

• DNI - do not incubate

Formula for pack years

# of packs/day x # of years smoked

Orthopnea

difficulty breathing except in the upright position (CHF)

Dyspnea

shortness of breath

What type of questions should you ask?

open ended

Environmental exposures

• asthma triggers

• heating cooling systems

• occupational exposure

• second hand smoke

Patient/Family history

1. History of present illness

2. Past medical history

3. Family history

4. Social history

Jaundice

increased bilirubin level in the blood and tissue

pectus carinatum

anterior protrusion of the sternum

pectus excavatum

depression of the sternum

kyphosis

curvature of the spine that makes you lean forward

kyphoscoliosis

a combination of kyphosis and scoliosis that causes a restrictive pattern (reduced lung volumes)

Barrel chest

increased AP diameter, generally due to COPD

Eupnea

normal respiratory rate, depth, and rhythm

Tachypnea

increased respiratory rate (>20 bpm)

cause: hypoxia, fever, pain, CNS problem

Bradypnea (Oligopnea)

decreased respiratory rate (<12 bpm) variable depth and irregular rhythm

cause: sleep (normal), drugs, alcohol, metabolic disorders

Apnea

no breathing

Hyperpnea

increased respiratory rate, increased depth, regular rhythm

cause: metabolic disorders/CNS disorders

Cheyne-Stokes

gradually increasing then decreasing rate and depth in a cycle lasting from 30-180 seconds, with periods of apnea lasting up to 60 seconds

cause: increased intracranial pressure, brainstem injury, drug overdose

Biot’s

increased respiratory rate and depth with irregular periods of apnea

cause: CNS problem

Kussmaul’s

increased respiratory rate (usually >20 bpm), increased depth, irregular rhythm, breathing sounds labored

cause: metabolic acidosis, renal failure, diabetic ketoacidosis

Apneustic

prolonged gasping inspiration followed by extremely short, insufficient expiration

cause: problem with respiratory center, trauma or tumor

Normal respiratory rate

12-20 bpm

Atrophy, cachexia, or starvation

muscle wasting/loss of muscle tone

occurs in paralysis

Intercostal and/or Sternal Retractions

when the chest moves inward during inspiratory efforts instead of outward

cause: severe airway obstruction or respiratory distress

Nasal flaring

flaring of the nostrils during inspiration

a sign of respiratory distress in infants

What might a dry or non-productive cough indicate?

tumor in the lungs

What might a productive cough indicate?

infection or chronic lung disease

What does Tachycardia indicate?

hypoxemia, anxiety, stress (recommended oxygen therapy)

What does Bradycardia indicate?

heart failure, shock, code/emergency (recommended atropine)

Tracheal deviation

• palpitation can be used to determine tracheal position

  • place index fingers into the supra-sternal notch

  • compare the space between the left clavicle and the left border of the trachea

Tracheal deviation: pulled to abnormal side (toward pathology) causes

1. pulmonary atelectasis

2. pulmonary fibrosis

3. pneumonectomy

4. diaphragmatic paralysis

Tracheal deviation: pushed to normal side (away from pathology) causes

1. massive pleural effusion

2. tension pneumothorax

3. neck or thyroid tumors

4. large mediastinal mass

Resonant

normal air filled lung

hollow sound

Flat

normally heard over the sternum, muscle, or areas of atelectasis

Dull

normally heard over fluid filled organs such as the heart or liver

cause: pleural effusion or pneumonia

thudding sound

Tympanic

normally heard over air filled stomach

indicates increased volume when heard over the lungs

drum like sound

Hyperresonant

can be heard in an area of the lung where either a pneumothorax or emphysema may be present

booming sound

Normal breathing sounds

vesicular

Bronchial breath sounds

normal sounds heard over the trachea or bronchi

if over the lungs, indicates lung consolidation

Egophony

patient is instructed to say “E” and it sounds like “A”

indicates consolidation of the lung tissue and a pneumonia like condition

Bronchophony

refers to increases intensity or transmission of the spoken voice

indicates consolidation and pneumonia

Abnormal breath sounds

adventitious

Crackles/Rales

secretion/fluid

Coarse crackles (rhonchi)

large airway secretions

cleared with cough or suction

Medium crackles

middle airway secretions

recommended bronchial hygiene

Fine crackles (moist crepitant rales)

alveoli, fluid

associated with CHF/pulmonary edema

recommended:

• oxygen

• positive pressure therapy

• positive inotropic therapy

• diuretics

Wheeze

most commonly caused by bronchospasm

recommended bronchodilator

Unilateral wheeze

indicative of foreign body obstruction

Stridor

high pitched or crowing inspiratory sound

cause: upper airway obstruction

Pleural friction rub

coarse, grating, raspy or crunching sound

cause: visceral and parietal pleura rubbing together

may be associated with pleurisy

recommended steroids and antibiotics

What creates normal heart sounds?

the closing of the heart valves

S3

suggests heart failure

S4

indicative of uncontrolled hypertension or aortic stenosis

What are heart murmurs caused by?

turbulent blood flow or heart valve defects

Blood Pressure (Systemic Arterial)

uses a sphygmomanometer to measure the systolic and diastolic pressures

normal: 120/80 mmHg

What are normal ranges for systolic and diastolic?

systolic: 90-140 mmHg

diastolic: 60-90 mmHg

Hypertension and Hypotension

increased BP and decreased BP

What is normal temperature and fever?

98.6 and 101+

How do you check for pitting edema and rate it?

push down on the skin, rate by #: the higher the number, the worse it is

Emaciated

weak

Hypercapnea

high Co2 levels

Pulse points

• radial (wrist)

• carotid (neck)

• femoral (groin)

• brachial (humerus)

• popliteal (behind knee)

• dorsalis (foot)

Hypovolemia

reduced blood volumes

Percussion

tap between ribs

What does pleural effusion sound like during pecussion?

dull

hypersonet

extra air

hyposonet

less air

What do patients with pleural friction rub usually have?

Pleurisy

Where is the most forceful heart generated from?

left ventricle

Capillary refil

3-5 seconds

Clubbing causes

CHF and bronchectosis

Purpose of bedside assessment

identify diagnosis and evaluate ongoing effects of treatment

What are the 2 key sources of patient data?

1. medical history

2. physical examination

Differential diagnosis

when signs and symptoms are shared by many diseases and the exact cause is unclear

Signs

objective - measured

Symptoms

subjective - stated by patient

Purpose of interviewing

• establish a rapport

• obtain information

• monitor changes

Factors effecting communication

• sensory and emotional factors

• environmental factors

• verbal and nonverbal components

• cultural values and beliefs

Technique for interviewing

1. introduce yourself in social space (4-12ft.)

2. interview in personal space (2-4ft.)

3. use eye contact

4. position yourself at the same level

5. avoid leading questions

How to close an interview

ask if they have anything they want to discuss and tell them when you’ll return

Is dyspnea and breathlessness signs or symptom?

symptoms

How is orthopnea triggered?

when patient reclines

Who commonly has orthopnea?

patients with CHF, mitral valve disease, and SVC syndrome

How is platypnea triggered?

when patient sits upright

Who commonly has platypnea?

patients with chronic lung disease and pneumectomy

Orthodeoxia

oxygen desaturation on assuming an upright position

Trepopnea

when lying on one side relieves dyspnea

(ex. pneumonia on left side, relieved by lying on left side)

Breathing into a paper bag

raises Co2

good for hyperventilating

Dry nonproductive cough

CHF

Loose productive cough

bronchitis and asthma

What is the most common cause of a cough

viral infection of the upper airway

If a patient can’t take a deep breath

they can’t cough

Chronic cough

lasts 8 weeks or longer

What does the effectiveness of a cough depend on?

1. ability to take a deep breath

2. lung elastic recoil

3. expiratory muscle strength

4. level of airway resistance

Causes of chronic cough

• upper airway cough syndrome (UACS) - >90%

• asthma

• gastroesophageal reflux

Phlegm

noncontaminated, can be suctioned

Sputum

mucus from lower airways

Purulent

• sputum containing pus cells

• thick and sticky

  • suggests bacterial infection