PATIENT ASSESMENT

Orthopnea

difficulty breathing except in the upright position

Orthopnea is associated with

CHF

General malaise

Run down feeling, nausea, weakness, fatigue, headache

General malaise is associated with

electrolyte imbalance

Dyspnea

a feeling of shortness of breath or difficulty in breathing

Pack years

number of packs a day x of years smoked

Normal urine output

40 mL/hr ( approx 1 Liter a day )

Examples of sensible water loss

( what you can measure )

urine and vomiting

Examples of insensible water loss

( what you cant measure )

lungs and skin

Changes in central venous pressure can indicate changes in

fluid balance

Normal CVP

2-6 mmHg

Decreased CVP

<2 mmHg

Decreased CVP can indicate

hypovolemia ( recommend fluid therapy )

Increased CVP

> 6 mmHg

Increased CVP can indicate

hypervolemia ( recommend diuretics )

Peripheral edema

Presence of excessive fluid in the tissue known as pitting edema

Peripheral edema occurs primarily in

arms and ankles

Causes of peripheral edema include

CHF and renal failure

Ascites

accumulation of fluid in the abdomen generally caused by liver failure

Clubbing of fingers caused by

Chronic hypoxemia

( presence of this us suggestive of pulmonary disease )

Erythema

redness of the skin may be caused by capillary congestion, inflammation or infection, flushed.

Barrel chest

a result of air trapping in the lungs for a long period of time

Barrel chest due to

chronic obstructive pulmonary disease

• increase in A-P diameter

Eupnea

normal respiratory rate, depth and rhythm

Tachypnea

increased respiratory rate ( greater than 20 breaths per min )

Normal respiratory rate for an adult

12-20 bpm

Cause for tachypnea

hypoxia, fever, pain and CNS problem

Bradypnea

decreased respiratory rate ( less than 12 per minute ) variable depth and irregular rhythm

Causes of bradypnea

sleep ( normal ) , drugs, alcohol, metabolic disorders

Apnea

cessation of breathing

Hyperpnea

Increased respiratory rate, increased depth, regular rhythm

Causes of hyperpnea

metabolic disorder ? CNS disorders

Cheyne strokes

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

Cause of cheyne stokes

increased intracranial pressure, brainstem injury, drug overdose

Biots

increased respiratory rate and depth with irregular periods of apnea, each breath has the same depth

cause: CNS problem

Kussmaul’s

increased rr ( usually over 20 breaths/min ), increased depth, irregular rhythm, breathing sounds labored

Kussmaul’s cause

Hypoxemia, metabolic acidosis, renal failure, diabetic ketoacidosis

Apneustic

prolonged gasping inspiration followed by extremely short, insufficient expiration.

Causes of apneustic

problems with respiratory center, trauma or tumor

Hypopnea

shallow or slow breathing

Hyperthrophy

increase in muscle size

accessory muscles occurs with COPD

Atrophy

muscle wasting, cachexia, starvation

is loss of muscle tone and occurs in paralysis

Mallampati Classification Class one

Soft palate, uvula, fauces, pillars visible

Mallampati Classification Class Two

Soft palate, uvula, fauces visible

Mallampati Classification Class Three

Soft palate, base of uvula visible

Mallampati Classification Class Four

Hard palate only visible

Considered difficult airways

class 3 and 4

Normal pulse

60-100 a minute

Tachycardia

> 100 indicates hypoxemia, anxiety, stress ( recommended oxygen therapy )

Bradycardia

<60 indicates heart failure, shock, code/emergency ( recommended atropine )

Paradoxical pulse/pulsus paradoxus

pulse/ blood pressure varies with respiration, may indicate severe air trapping

( status asthmaticus, tension pneumothorax , cardiac tamponade )

Pulled to abdominal side

( toward pathology )

• pulmonary atelectasis

• pneumonectomy

• diaphragm paralysis

Pushed to normal side

( away from pathology )

• massive pleural effusion

• tension pneumothorax

• neck or thyroid tumors

• large mediastinal mass

Vocal Fremitus

voice vibrations on the chest wall

Pleural rub fremitus

a grating sensation felt on the chest wall due to roughened pleural surfaces rubbing together

Rhonchal fremitus ( palpable rhonchi )

secretions in the airways

Crepitus

Bubbles of air under the skin that can be palpated and indicates the presence of subcutaneous emphysema

Resonant

normal, air filled lung, this gives a 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. Pleural effusion or pneumonia will cause this thudding sound

Tympanic

normally heard over air filled stomach, this is a drum like sound and indicates increased volume when heard over the lungs

Hyperresonant

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

Crackles ( rales )

secretions and fluid

Coarse crackles

( rhonchi that can clear with a cough )

large airway secretions

( suction pt to cough or suction )

Medium crackles

middle airway secretions

• recommend bronchial hygiene

Fine crackles

moist crepitant rales

alveoli, fluid, associated with CHF / pulmonary edema

What to recommend on fine crackles?

• oxygen

• positive pressure therapy

• positive inotropic agents

• diuretics

Wheeze

Most commonly caused by bronchospasm

• recommend bronchodilator therapy for diffuse/ bilateral wheezing

• Unilateral wheeze indicative of a foreign body obstruction

Stridor

High pitched or crowing inspiratory sound

• caused by airway obstruction

• supraglottic swelling ( epiglottitis )

• subglottic swelling ( croup, post extubation )

• Foreign body aspiration ( solids or fluid )

Stertor

Noisy breathing that occurs during inhalation

• low pitched snoring type of sound that usually arises from the vibration of fluid or the vibration of tissue that is relaxed or flabby

Pleural friction rub

• coarse grating, raspy or crunching sound

• caused by inflamed surface of the visceral and parietal pleural rubbing together \

• may be associated with pleurisy, TB, pneumonia, pulmonary infarction, cancer

• recommend steroids and antibiotics

Normal heart sounds

s1 and s2

Abnormal heart sounds

s3 and s4

Adult normal BP

120/80

Acceptable systolic range

90-140 mmHg

Acceptable diastolic range

60-90 mmHg

AP projection

X-rays travel from anterior to posterior, image receptor behind back, commonly used fro bedridden pts

PA projection

X rays travel from posterior to anterior, image receptor touching the chest with patients back to X-ray tube

Lateral decubitus position

patient lying in the affected side

• valuable for detecting small pleural effusions

Apical lordotic

projection of lung apices

• tuberculosis remains in there

Croup ( laryngotracheobronchitis )

The X-ray of the neck will reveal tracheal narrowing with subglottic swelling in a classic pattern

• steeple sign

• picket fence sign

• pencil point sign

• hourglass sign

Epiglottis

A lateral neck X-ray shows supraglottic narrowing with an enlarged and flattened epiglottis and swollen aryepiglottic folds

Radiolucent

Dark pattern, air

Radiolucent Diagnosis

Normal for lungs

Radiodense / Opacity

White pattern, solid, fluid

Radiodense / Opacity Diagnosis

Normal for bones and organs

Infiltrate

Any ill defined radiodensity

Infiltrate diagnosis

atelectasis

Consolidation

Solid white area

Consolidation diagnosis

Pneumonia/ pleural effusion

Hyperlucency

Extra pulmonary air

Hyperlucency diagnosis

COPD, asthma attack and pneumothorax

Vascular Markings

lymphatics, vessels and lung tissue

Vascular markings diagnosis

Increased with CHF absent with pneumothorax

Diffuse

spread throughout

Diffuse diagnosis

Atelectasis/ pneumonia

Opaque

fluid or solid

Opaque diagnosis

Consolidation

Pulmonary edema terminology

• fluffy infiltrates

• butterfly pattern

• batwing pattern

Pulmonary edema description

• Diffuse whiteness

• Infiltrate in shape of butterfly