PT531 (Week 2) and 628 (Week 1): The Cardiopulmonary Evaluation

what information should you review in the patients chart?

Demographics: Name, DOB, Gender

History in Progress (HIP): symptoms on Admission, Diagnosis (Dx), Procedures

PMH

Meds

Labs

Diagnostic Testing

Precautions/Orders

Risk Factors

The heart and Lungs are within which body cavity?

thorax

The heart is located in what region?

mediastinum

The connective tissue around the heart is the?

pericardium

The connective tissue around the lungs is the?

pleura

Where is the most superior aspect of the lungs?

above the clavicle

Where is the most inferior aspect of the lungs?

exhalation: T10

inhalation: T12

The R lung has _______lobes?

3

TheL lung has _______lobes?

2 and the lingula

The bifurcation of the trachea is at what anatomical location?

sternal angle

T4

where is the horizontal fissure of the lungs?

around 4th intercostal space

where are the middle lobe and lingula located?

axillary

where is the lower margin of the lungs?

ribs 6-8 -> on a slant

6th rib at the midcalvicular line, 8th rib at midaxillary line

what do pulmonaryarteries carry?

deoxygenated blood to the lungs

what often causes right sided HF?

pulmonary hypertension

what causes pulmonary hypertension?

lung disease, idiopathic

how does lung disease cause pulmonary hypertension?

the body vasoconstricts the blood vessels to the diseased part of the lung to try and save energy

this saves energy as the body is failing to perfuse this part of the lung and once it realizes this, it will stop

to comepnsate, the body will dilate blood vessels in other areas of the lung to try and get perfusion there

what are the muscles of normal inspiration?

diaphragm

external intercostals

what are the muscles of normal expiration?

none!

results from passive, elastic recoil of the lungs, rib cage, and diaphragm

what are the muscles of forced expiration?

internal intercostals

abdominals

what are accessory muscles of breathing?

SCM

trapezius

pectoralis minor

scalenes

what may we do with our muscles if we are having trouble breathing?

may recruit accessory muscles

will become upper chest breathers and not diaphragmatic breathers

what are the 4 parts of the cardio exam?

inspection

palpation

percussion

ausculation

what should you be inspecting in the cardiac exam?

skin

accessory muscle use

retractions

jugular vein distention

thorax shape and expansion

scars

breathing pattern

signs of distress

digital clubbing

what should inspect the skin for?

temperature

color -> cyanosis, jaundice

what is jaundice?

A yellowing of the skin and eyes

what is the mechanism of jaundice?

buildup of bilirubin

bilirubin is a byproduct of RBC breakdown

bilirubin usually added to bile and excreted from the body

what causes jaundice?

usually liver disease (end stage)

also pancreatic diseases pressing on the bile duct

what is cyanosis? what does this cause?

lack of O2

causes discolored (often blue) lips, face, fingers, toes

what is the SpO2 if someone has cyanosis?

mid to low 80s or lower

what should you inspect for accessory muscle use?

Hypertrophy of SCM, scalenes and upper trap seen with chronic pulmonary conditions

what are retractions?

when a patient has a hard time breathing, this decreases the air getting to the lungs

this causes a lower pressure in the lungs compared to the atmosphere

this causes no rise of the chest and sinking in of the skin (ribs) when the patient breathes in

how should you assess for jugular vein distention?

Assess in recumbent position with HOB up 45 degrees

have patient turn their head to the one side

Positive if distended vein above the clavicle

what may cause a distention of the jugular vein?

heart failure

ex. R sided heart failure -> when patient turns their head to the L, the blood will back up into the venous system if they have HF

what is the normal thorax shape?

anterior to psoterior diameter is usually half of the size of the transverse diameter

what is barrel chest?

Increased anterior-posterior diameter of chest

what may cause barrel chest?

obstructive lung disease -> air stuck in lungs

what is pectus excavatum?

bottom part of the sternum tilts in

divvet where the sternum is

what is pectus carinatum?

sternum tilts out at the bottom

what type of scars should you observe for?

sternotomy incision

thoracotomy incision

when is a thoracotomy incision see?

usually for a surgery to access the lungs (ex. for cancer, infection, lung reduction)

what is a sternotomy incision seen?

seen with open heart surgery

do you need to follow sternal precautions with a thoracotomy?

no

just avoid heavy lifting and encourage AROM

what may patients do to guard their incision?

may sink in or slouch

encourage good posture! may need to use pillows

what is the normal respiratory rate?

Normally respiration is 12-20 breaths per minute at rest in the adult

12-25 in elderly

what is the normal inspiratory to expiratory ratio?

1:2

what is bradypnea?

slow breathing

what is tachypnea?

fast breathing

what is hyperpnea?

normal rate and rhythm, increased depth

what is orthopnea?

Difficulty breathing when lying flat

what is dyspnea?

Difficulty breathing, usually high rate and shallow (hypoventilation)

what is hyperventilation?

Fast rate with increased depth, regular rhythm

what is Cheyenne-stokes breathing pattern?

increasing depth with periods of apnea- critically ill

when are Biot's and Apneustic breathing patterns seen?

irregular associated with brainstem/CNS disorder

what signs of distress should you look for?

pain

difficulty breathing

why do people put their hands on their legs and lean over when they have trouble breathing?

fixes the UE and allows you to use accessory muscles

what is digital clubbing?

when the ends of the figers are more round and bulbous

when is digital clubbing seen?

Seen with chronic tissue hypoxia (lack of O2)

What are some things you may see on inspection if a patient has CHF?

SOB

JVD

cyanosis

orthopnea

swelling

What are some signs that your patient is having difficulty breathing?

accessory muscle use

tripod sign

increased RR

cyanosis

what is the tripod sign?

rest hands on something (like legs) to use accessory muscles to help you breathe

How does pain effect breathing?

increases RR but decreases depth

hypoventilation!!

what should you palpate?

PMI (point of maximal impulse of the heart)

Position of the trachea

Chest Expansion

Tactile Fremitus

Edema

Pulses

Capillary Refill

what is PMI?

where you can feel the apical pulse of the heart

what is normal PMI?

at the midclavicular line between the 4th and 5th intercostal spaces

what does it mean if PMI is more lateral and/or inferior?

enlargement of heart

where should the trachea normally be?

in midline

how and why can the trachea deviate?

The trachea will deviate toward reduced pressure or away from greater pressure

ex. away from a mass, towards a collapsed lung

if there is an acute tracheal deviation, what does this mean?

usually emergent -> pneumothorax

how should you palpate the upper lobes of the chest?

thumbs at clavicle (NOT ABOVE) and fingers over upper trap

how should you palpate the middle lob and lingula?

at nipple line or just below

how should you palpate the lower lobes of the lungs?

at T10 -> posterior

what part of the lungs should you feel the most chest expansion?

lower lobes

what are we feeling for with chest expansion?

depth and symmetry

What are potential causes of reduced lung expansion?

lung disease

abdominal problems

rib fx

poor posture -> increased kyphosis

paralysis of diaphragm

what is tactile fremitus?

Vibration that is produced by the presence of secretions in the airways or consolidation in the lung tissue and is transmitted to the chest wall and palpated by the hands.

how do you palpate tactile fremitus?

Place your flat hand or ulnar border of the hand over skin

Ask the patient to say 99

feeling for incraesed vibration

Cover all lung surfaces

what are some causes of edema?

CHF

Trauma

Kidney/liver disease

Blood Clot

is edema biateral or unilateral with CHF?

bilateral

is edema biateral or unilateral with trauma?

specific to area of injury

is edema biateral or unilateral with a blood clot?

unilateral -> where the blood clot is

where does pitting edema happen first with heart and organ failure?

dorsum of the foot and the medial malleolus

what is the pitting edema scale scoring?

1+

2+

3+

4+

pitting edema scale: 1+

barely preceptible depression

pitting edema scale: 2+

easily identifiable depression

skin rebounds within 15 seconds

pitting edema scale: 3+

easily identifiable depression

skin rebounds in 15-30 seconds

pitting edema scale: 4+

easily identifiable depression

skin rebounds in >30 seconds

how can you assess girth?

with a tape measure

where do you assess girth?

Assess Largest portion of the calf Bilaterally in Cm.

Compare sides

where should you palpate pulses?

brachial, radial, femoral, popliteal, dorsalis pedis, psoterior tibialis

how do you assess capillary refill?

pinch the tip of the finger or toe

should see a color blanch and noralize in < (or equal to) 3 seconds

what information can mediate percussion give you?

Fluid or air trapping in lungs

Lung expansion

Function of diaphragm

how do you assess mediate percussion?

put middle finger of non-dominant hand on the intercostal space you are assessing

tap that finger with your opposite middle finger (with dominant hand)

should hear a resonant sound (over air)

how can you use mediate percussion to assess diaphragmatic expansion/excursion?

as you move down (on the back), sounds go from resonant to dull

if you have the pt take a deep breath in and do this again, you will hear resonant further down the back as the diaphragm expands and the lungs fill with air

what does it mean if you hear a dull sound with mediate percussion?

fluid around the alveoli (CHF, pneumonia, pleural effusion)

what does it mean if you hear an echo (hyper-resonant) with mediate percussion?

air trapping (COPD, pneumothorax)

what are the normal heart sounds?

S1 lub

S2 dub

what does S1 represent in normal heart sounds?

closure of AV valves

what does S2 represent in normal heart sounds?

closure of semilunar valves

with what side of the stethoscope should you use to listen for heart sounds?

both the diaphragmatic and bell sides (first diaphragmatic then bell)