Advanced Patient Assessment: Inspection, Palpation, and Percussion Study Notes

Overview of Advanced Patient Assessment

  • Focus Area: This chapter covers the advanced assessment techniques of inspection, palpation, and percussion to evaluate patient health, specifically focusing on respiratory and skeletal findings.
  • Fundamental Assessment Techniques:
    • Inspection: Visual observation of the patient.
    • Palpation: Physical examination through touch.
    • Percussion: Tapping on the chest or abdomen to determine the density of the underlying tissue.

Clinical Inspection: General Findings and Respiratory Status

  • Initial Observational Parameters:

    • Skin Color: Assessment of the patient's integumentary color for signs such as cyanosis or pallor.
    • Work of Breathing (WOB): Evaluation of the effort required for respiration.
    • Conformation of Digits: Checking the shape and state of the fingers and toes.
    • Respiratory Rate, Rhythm, and Pattern: Monitoring how often and how regularly a patient breathes.

  • Normal Breathing Pattern:

    • Eupnea: The term used to describe normal, quiet, rhythmic breathing.

Inspection of the Chest: Abnormal Respiratory Patterns

  • Hyperpnea:

    • Definition: A respiratory pattern characterized by a greater than normal depth of respiration.

  • Hypopnea:

    • Definition: A respiratory pattern characterized by a decreased depth of respiration.

  • Kussmaul’s Respiration:

    • Definition: A rhythmic respiratory pattern characterized by an increase in both the rate and depth of breathing.
    • Clinical Association: Often associated with a diabetic crisis (diabetic ketoacidosis).

  • Cheyne-Stokes Respiration:

    • Definition: A periodic breathing pattern characterized by a gradual increase in depth and respiratory rate, followed by a gradual tapering of the rate and depth, which ultimately leads to periods of apnea (the absence of respirations).
    • Clinical Associations: Congestive Heart Failure (CHF), trauma or damage to the Central Nervous System (CNS), and increased cerebrospinal fluid pressure.

  • Biot’s Respiration:

    • Definition: A respiratory pattern that is irregular in both rate and depth.
    • Clinical Association: Often observed in patients with meningitis.

Inspection of the Chest: Work of Breathing and Positioning

  • Observation of Patient Position:
    • Tripod Position: A clinical sign of respiratory distress where the patient sits or stands leaning forward and supporting their upper body with their hands on their knees or another surface.
  • Accessory Muscle Use: Observing if the patient is recruiting extra muscles (such as the sternocleidomastoids or intercostals) to assist with breathing.
  • Speech Evaluation: Assessing the patient’s ability to speak in complete sentences, which provides an indication of their respiratory reserve and effort.

Inspection of the Chest: Skeletal Abnormalities and Digits

  • Barrel Chest:

    • Description: A rounded, bulging chest shape.
    • Cause: Associated with chronic lung disease due to chronic air trapping and a subsequent loss in lung compliance.

  • Kyphosis (Humpback):

    • Description: An exaggerated outward curvature of the thoracic spine.
    • Clinical Association: Frequently observed in chronic lung disease.

  • Scoliosis: A lateral or sideways curvature of the spine.

  • Kyphoscoliosis: A combination of both kyphosis (inward/outward curvature) and scoliosis (lateral curvature).

  • Pectus Excavatum (Funnel Chest): A congenital deformity where the sternum is sunken into the chest.

  • Pectus Carinatum (Pigeon Chest): A deformity of the chest characterized by a protrusion of the sternum and ribs.

  • Digital Clubbing:

    • Description: A bulbous enlargement of the ends of the fingers or toes.
    • Clinical Association: A sign of chronic lung disease.

Palpation of the Chest

  • Assessment Areas:
    • Areas of Tenderness: Identifying specific spots where the patient feels pain upon touch.
    • Tactile Fremitus: Feeling for vibrations transmitted through the chest wall while the patient speaks.
    • Subcutaneous Emphysema: Identifying the presence of air in the subcutaneous tissues, which often feels like a crackling sensation (crepitus) under the skin.
    • Tracheal Deviation: Palpating to ensure the trachea is midline; deviation can indicate various intrathoracic pathologies.
    • Skin Temperature: Using the hands to assess for localized or systemic changes in temperature.

Percussion of the Chest

  • Percussion Notes and Findings:
    • Hyperresonance: An abnormally loud, low-pitched sound typically heard over areas of increased air (e.g., pneumothorax or emphysema).
    • Resonance: The normal, low-pitched, hollow sound heard over healthy lung tissue.
    • Dullness: A thud-like sound heard over dense organs (like the liver) or when fluid occupies the pleural space.
    • Flatness: An extremely dull sound produced by very dense tissue, such as muscle or bone.