chapter 16
Introduction
- Clinical assessments helps physicians make decisions regarding when to initiate, change, or discontinue therapy depend upon accurate
- Physician is responsible, but RTs participate in clinical decision making - Bedside assessment:
- Process of interviewing and examining patient for signs and symptoms of disease
- Evaluating the effects of treatment
- Inexpensive and little risk to patient
- Part of initial assessment to identify diagnosis and to evaluate ongoing effects of treatment
- Data gathered during the initial interview and physical examination help identify the need for subsequent diagnostic tests
- Two key sources of patient data
- Medical history
- Physical examination
- Patient initially is assessed to identify the correct diagnosis
- Diagnosis is the process of identifying the nature and cause of illness - Differential diagnosis is the term used when signs and symptoms are shared by many diseases and the exact cause is unclear
- Signs refer to the objective manifestation of illness
- Symptoms refer the sensation or subjective experience of some aspect of an illness
Interviewing the Patient and Taking a Medical History
- Purposes
- To establish a rapport between the clinician and patient
- To obtain information essential for making a diagnosis
- To help monitor changes in the patient’s symptoms and response to therapy
Principles of Interviewing
- Interviewing is the process of gathering relevant information from a patient - An essential element of which involves establishing rapport
- Factors affecting communication between the RT and the patient include the following:
- Sensory and emotional factors
- Environmental factors
- Verbal and nonverbal components of the communication process - Cultural and other internal values, beliefs, feelings, habits, and preoccupations of both the RT and the patient
Structure and Technique for Interviewing
- Introduce yourself in social space (~4-12 feet)
- Interview in personal space (~2-4 feet)
- Use appropriate eye contact
- Assume physical position at same level as patient
- Avoid use of leading questions; use neutral questions
Common Cardiopulmonary Symptoms
- Dysnea
- Sensation of breathing discomfort by patient (subjective feeling) - Most important symptom RT is called upon to assess and treat - Breathlessness
- Sensation of unpleasant urge to breathe
- Can be triggered by acute hypercapnia, acidosis, and hypoxemia
Positional Dyspnea
- Orthopnea
- Dyspnea that is triggered when the patient assumes the reclining position - Common in patients with CHF, mitral valve disease, and superior vena cava syndrome
- Playynea
- Dyspnea triggered by assuming the upright position
- Typically occurs in patients following pneumonectomy and in those with chronic liver disease (hepatopulmonary syndrome)
- Sometimes observed during hypovolemia and in some neurologic diseases
- Orthodeoxia
- Oxygen desaturation on assuming an upright position
- Accompanies playnea
- Treponea
- When lying on one side relieves dyspnea
- Usually associated with either CHF or pleural effusion
Language of Dyspnea
- RT should try to categorize each sensation according to a particular aspect of breathing
- Inspiration, expiration, respiratory drive or lung volume
- Ask patient about quality and characteristics of dyspnea (may provide insight into its causes)
- Patients with asthma frequently complain of chest tightness
- Patients with interstitial lung disease may complain of increased WOB, shallow breathing, and gasping
- Patients with CHF may complain of feeling suffocated
- Patients with cardiopulmonary disease frequently experience several unpleasant breathing sensations simultaneously
Assessing Dyspnea during an interview
- Pay attention to whether patient can speak in full sentences
- If severe dyspnea the initial interview should be curtailed, and treatment should be initiated as soon as possible
- Questions should be brief and limited to quality and intensity of dyspnea and circumstances of symptom onset
- Assessment should correspond with gross examination of patient’s breathing pattern
- In patients with chronic cardiopulmonary disease, a detailed and systematic history should cover four major area:
- What ADL tend to trigger episodes of dyspnea
- How much exertion makes the patient stop to catch breath
- Whether the quality or sensations of breathing discomfort varies with different activities
- Ask the patient to recall when dyspnea first began and how it has evolved over time
Psychogenic Dyspnea
- Panic Disorders and Hyperventilation
- Psychogenic hyperventilation syndrome
- When patients have normal cardiopulmonary function complain of intense dyspnea and suffocation
- May coincide with symptoms, such as chest pain, anxiety, palpitation, and paresthesia
- Anxiety often accompanied by breathlessness and hyperventilation - RT must always approach any situation involving hyperventilation or dyspnea as if it had a pathogenic basis
- Vital signs, ABG, perhaps 12-lead ECG
Cough
- Most common, nonspecific symptom observed in patients with pulmonary disease
- Cough occurs when cough receptors in airways are stimulated by inflammation, mucus, foreign material , or noxious gases
- Often impaired in patients with:
- Cardiopulmonary, neurologic or neuromuscular diseases, postoperative period following upper abdominal surgery or thoracic surgery, after trauma due to pain
- RT should note characteristics of the patients cough
- Characteristics include:
- Dry or loose, productive or nonproductive, acute or chronic, and whether it occurs more frequently at particular times (ex. Day or night)
- A chronic cough is one lasting 8 weeks or longer
Causes of Chronic Cough
- Upper airway cough syndrome (UACS)
- Formerly known as “postnasal drip”
- Asthma
- Gastroesophageal reflux
- Chronic bronchitis associated with cigarette smoking
- ACE-1 Cough
- Caused by the antihypertensive drug angiotensin converting enzyme inhibitor
- Nonasthmatic eosinophilic bronchitis
Sputum Production
- Mucus from tracheobronchial tree not contaminated by oral secretion is called “phlegm”
- Mucus from lower airways but is expectorated though mouth is called “sputum” - Sputum having pus cells is said to be “purulent”
- Foul-smelling sputum is “fetid”
- Recent changes in sputum color, viscosity, or quantity may indicate infection
Hemoptysis
- Coughing up blood or blood-streaked sputum from the lungs
- Massive
- More than 300 ml of blood expectorated over 24 hours
- Common causes: bronchiectasis, lung abscess, and acute or chronic tuberculosis
- Distinguished from hematemesis (vomiting blood from gastrointestinal tract)
- Nonmassive
- Common causes include: infection or airway, tuberculosis, trauma, and pulmonary embolism
Chest Pain
- Pleuritic chest pain - located laterally or posteriorly
- Sharp and increases with deep breathing (pneumonia and pulmonary embolism)
- Nonpleuritic chest pain - located in center of chest and may radiate to shoulder or arm; it is not affected by breathing
- Often caused by angina, gastroesophageal reflux, esophageal spasm, chest wall pain, and gall bladder disease
Fever
- Elevation of body temperature due to disease (greater than 38.3 C; 101 F) - May occur with simple viral infection of upper airway or with serious bacterial pneumonia, tuberculosis, and some cancers
- Causes increased metabolic rate, oxygen consumption, and carbon dioxide production
- Particularly dangerous in patients with severe chronic cardiopulmonary disease because it may cause acute respiratory failure
-
Pedal Edema
- Swelling of lower extremities - most often due to heart failure
- Two subtypes:
- Pitting edema - indentation mark left on skin after applied pressure - Weeping edema - small fluid leak occurs a point where pressure applied - Patients with chronic hypoxemic disease usually develop right heart failure (corpulmonale) due to pulmonary hypertension
The Medical Record and Medical History
- The first priority of the RT reviewing the medical record is to ensure that all respiratory care procedures are supported by a physician order that is current, clearly, written, and complete
- Then review the patient’s medical record by reading about current medical problems
- Familiarizes clinician with patient's condition
- Reviewing patient’s chart:
- Chief complaint (CC)/history of present illness (HPI)
- Explains current medical problems
- Past medical history (PMI)
- Smoking history is often recorded in packs/year
- Packs smoked per day x number of years smoked
- Family/Social/Environmental history
- Potential genetic or occupational links to disease and the patient's current life situation
- Review of systems (ROS)
- Advance directive
Physical Examination
- Essential for evaluating patient’ problem and determining ongoing effects of therapy
- Consists of four steps:
1. Inspection (visually examining)
2. Palpation (touching)
3. Percussion (tapping)
4. Auscultation (listening with stethoscope)
General Appearance
- Done during first few seconds of patient encounter
- Indicators to assess
- Level of consciousness
- Facial expression
- Level of anxiety or distress
- Body positioning
- Personal hygiene
Level of Consciousness
- Sensorium
- Level of consciousness and orientation to time, place, person, and situation (oriented x 4)
- Reflects oxygenation status of brin
- Affected by poor cerebral blood flow (hypotension)
- If patient not alert - standard rating scale is used to objectively describe patient’s level of consciousness
Vital Signs
- Easy to obtain and provide useful information about current health status - VS provide first clue to adverse reactions to treatment
- Most frequent vital signs
- The body temperature, pulse rate, respiratory rate, and blood pressure - All thirsty dogs eat ice
- Atropine
Body Temperature
- Normal - 98.6 F or 37.0 C
- Hyperthermia or hyperpyrexia (fever) :increased temperature
- Caused by disease or from normal activities such as exercise
- Hypothermia: Decreased temperature
- Most common cause of hypothermia is prolonged exposure to cold - Less common causes include head injury or stroke, decreased thyroid activity, and overwhelming infection
- Can be measured at: mouth, axilla, ear, or rectum
- Rectal temp: closest to core body temperature
Pulse Rate
- Evaluate rate, rhythm, and strength
- Radial artery most common site to palpate
- Normal adult pulse rate is 60-100 beats/min
- Treat causes first
- Common causes are exercise, fear, anxiety, low BP, anemia, fever, hypoxemia, hypercapnia, and certain medications
- Bradycardia: HR < 60 beats/min
- Causes are hypothermia, as a side effect of medications, with certain cardigan arrhythmias, and with traumatic brain injury
- Spontaneous ventilation can influence pulse strength, or amplitude - A slight decrease in pulse pressure is normally present with each inspiratory effort
- Pulsus paradoxus - significant decrease in pulse strength ( >10 mmHg) during spontaneous inspiration
- Is common in patients with acute obstructive pulmonary disease, especially patients experiencing an asthma attack
- Pulsus alternans - alternating succession of strong and weak pulses
- Suggests left-sided heart failure and usually is not related to respiratory disease
Respiratory Rate
- Resting adult RR is 12-18 breaths/min
- Tachypnea >20 breaths/min
- Associated with exertion, fever, hypoxemia, hypercarbia, metabolic acidosis, anxiety, pulmonary edema, lung fibrosis, and pain
- Bradypnea <10 breaths/min
- May occur with traumatic brain injury, severe myocardial infarction, hypothermia, anesthetics, opiate narcotics, and recreational drug overdoses
Arterial Blood Pressure
- Systolic pressure is the peak force exerted in the major arteries during contraction of the left ventricle
- Systolic: 90-140 mm Hg
- Diastolic pressure is the force in the major arteries remaining after relaxation of the ventricles
- Diastolic: 60-90 mm Hg
- Pulse pressure - difference between systolic and diastolic
- Normal: 30-40 mm Hg
- Hypertension: BP persistently > 140/90
- Hypotension: Systolic BP < 90 mm Hg or mean arterial pressure < 65 mm Hg - Shock - inadequate delivery of O2 and nutrients to the vital organs relative to their metabolic demand
- Shock usually treated aggressively with fluids, blood products, or vasoactive drugs, or a combination of these
- Cardiogenic shock
- Hypovolemic shock
- Septic shock
- Anaphylaxis
- Postural hypotension
- Syncope
Examination of the Head and Neck
- Head
- Abnormal signs help indicate respiratory problems
- Nasal flaring: often seen in infants with respiratory distress - increased WOB
- Cyanosis of oral mucosa (central cyanosis) indicates respiratory failure due to low oxygen levels
- Pursed-lip breathing - seen in patients with COPD to prevent collapse of small airways
- Neck
- Inspection and palpation of the neck help determine the position of the trachea
- May shift away from midline in certain thoracic disorders
- Jugular vein distention (JVD) - seen in patients with CHF and cor pulmonale (failure of the right ventricle, enlargement and dysfunction due to high BP)
- Enlarged lymph nodes in neck may occur with infection or malignancy
Examination of the Thorax and Lungs
- Inspection
- Chest should be inspected visually to assess
- The thoracic configuration
- Expansion
- The pattern and effort of breathing
- Make every effort to respect the patient’s modesty
- Thoracic configuration
- The anteroposterior (AP) diameter of the average adult thorax is less than the transverse diameter
- The abnormal increase in AP diameter is called barrel chest
- Associated with emphysema
- Pectus carinatum
- Abnormal protrusion of sternum
- Pectus excavatum
- Depression of part or entire sternum, which can produce a
restrictive lung defect
- Kyphosis
- Spinal deformity in which the spine has an abnormal AP curvature - Scoliosis
- Spinal deformity in which the spine has a lateral curvature
- Kyphoscoliosis
- Combination of kyphosis and scoliosis, which may produce a
severe restrictive lung defect as a result of poor lung expansion
- Thoracic expansion
- Diaphragm is the primary muscle of breathing
- Normal chest wall expands symmetrically and can be evaluated on the anterior and posterior chest
- Diseases that affect the expansion of both lungs cause a bilateral reduction in chest expansion
- Reduced expansion commonly is seen in neuromuscular
disorders and COPD
- Unilateral reduction in chest expansion occurs with
respiratory diseases that reduce the expansion of one lung
or a major part of one lung
Breathing Pattern and Effort
- Abnormal breathing pattern - broken into two broad categories
- Those directly associated with cardiopulmonary or chest wall diseases that increase work of breathing
- Those associated with neurologic disease
- Common causes of an increase in WOB include:
- Narrowed airways (ex. COPD, asthma)
- “Stiff lungs” (ex. Acute respiratory distress syndrome, cardiogenic pulmonary edema)
- A stiff chest wall (ex. Ascites, anasarca, pleural effusions)
- One sign of severely increased work of breathing is visible distortions in chest wall, called retractions
- Retractions are an inward sinking of the chest wall during inspiration - Intercostal, supraclavicular, or subcostal retractions
- Occurs when inspiratory muscle contractions generate very large negative intrathoracic pressures
- Tracheal tugging
- Downward movement of the thyroid cartilage towards the chest during inspiration
- Two typical abnormal breathing patterns exist
1. A rapid, shallow breathing pattern
2. A relative brief inspiratory phase with an abnormally prolonged exhalation characterized by pronounced, sustained abdominal
muscular contraction
- Can provide clues about the underlying pulmonary problem
- Apnea
a. Characteristic - No breathing
b. Causes - Cardiac arrest, narcotic overdose, severe brain trauma - Apneustic breathing
- Characteristic - Deep, gasping inspiration with brief, partial expiration
- Causes - Damage to upper medulla or pons caused by stroke or trauma, sometimes observed with hypoglycemic coma or profound hypoxemia
- Ataxic breathing
- Characteristic- Completely irregular breathing pattern with variable periods of apnea
- Causes - damage to medulla
- Asthmatic breathing
- Characteristic - Prolonged exhalation with recruitment of abdominal muscles
- Causes - Obstruction to airflow out of the lungs
- Biot respiration
- Characteristics - Clustering of rapid, shallow breaths coupled with regular or irregular periods of apnea
- Causes - Damage to medulla or pons caused by stroke or trauma, severe intracranial hypertension
- Cheyne-Stokes respiration
- Characteristics - Irregular type of breathing, breaths increase and decrease in depth and rate with periods of apnea, variant of “periodic breathing”
- Causes - Most often caused by severe damage to bilateral cerebral hemispheres and basal ganglia (usually infarction), also seen in patients with CHF owing to increased circulation time and in various forms of encephalopathy
- Kussmal breathing
- Characteristics - Deep and fast respirations
- Causes - Metabolic acidosis
- Paradoxical breathing
- Abnormal paradox -
- Characteristic - Abdominal wall moves inward on inspiration and outward on expiration
- Causes - Diaphragmatic fatigue or paralysis
- Chest paradox
- Part or all of the chest wall moves in with inhalation and out with exhalation
- Causes - Typically observed in chest trauma with multiple rib or sternal fractures, also found in patients with high spinal
cord injury and paralysis of intercostal muscles
- 3 or more ribs causes flail chest
- Periodic breathing
- Characteristic - Breathing oscillates between periods of
rapid, deep breathing and slow, shallow breathing without
periods of apnea (cheyne stokes without apnea)
- Causes - Most often caused by severe damage to bilateral
cerebral hemispheres and basal ganglia (usually infarction),
also seen in patients with CHF owing to increased circulation
time and in various forms of encephalopathy
- Ninety nine - Technique to hear lung consolidation
- Normal - sound muffled, words indistinct, mild
vibrations
- Abnormal - sound clear, loud, distinct, increased
vibrations
Diaphragmatic Fatigue
- Found in many types of chronic and acute pulmonary diseases - Signs of acute fatigue
- Tachypnea
- Diapham and rib cage muscles take turns powering breathing (respiratory alternans)
- Abdominal paradox occurs with complete diaphragmatic fatigue - Hoover sign
- Lower ribs move inward during inspiration, indicating severe
obstructive airway disease like COPD
Chest Palpation
- Palpation is the art of touching the chest wall to evaluate underlying structure and function
- Vocal and tactile fremitus is increased with pneumonia and atelectasis (consolidation)
- Vocal and tactile fremitus is reduced with emphysema, pneumothorax, and pleural effusion
- Bilateral reduction in chest expansion
- seen in neuromuscular disorders and COPD
- Unilateral reduction in chest expansion
- consistent with pneumonia or pneumothorax
- Air leaks into subcutaneous tissues causes “crepitus”
- sign of subcutaneous emphysema
Percussion over lung fields
- Performed systemically by consecutively testing comparable areas on both sides of the chest
- Resonance of chest evaluated with percussion
- Findings should be labeled as “normal”, “increased”, or “decreased” resonance - Decreased resonance - pneumonia or pleural effusion (consolidation) - Increased resonance - emphysema or pneumothorax (air)
Auscultation of the Lungs
- Tracheal breath sounds
- Heard directly over trachea, created by turbulent flow, loud with expiratory component equal to or slightly longer than inspiratory component
- Bronchovesicular breath sounds
- Heard around sternum, softer and slightly lower in pitch
- Vesicular breath sounds
- Heard over lung parenchyma, very soft and low pitched
- Normal breath sounds
- Lung sounds are audible vibrations primarily generated by turbulent airflow in the larger airways
- Sounds are altered as they travel through the lung periphery and chest wall
- Normal lung tissue acts as a low-pass filter
- It preferentially passes low frequency sounds
- Adventitious lung sounds - abnormal lung sounds
- Two varieties
1. Discontinuous
a. Intermittent crackling
b. Bubbling sounds of short duration
c. Refereed to as “crackles”
2. Continuous
a. Referred to as “wheezes”
b. Heard over the upper airway is called “stridor”
- Bronchial breath sounds
- Abnormal if heard over peripheral lung regions
- Replacing normal vesicular sounds when lung tissue density increases - Diminished breath sound
- Occur when sound intensity at site of generation (larger airways ) is reduced due to shallow or slow breathing or
- When sound transmission through lung or chest wall is decreased (COPD or asthma)
- Wheezes
- Consistent with airway obstruction
- Monophonic wheezing indicates one airway is affected
- Polyphonic wheezing indicates many airways are involved
- Stridor
- Upper airway compromised
- Chronic stridor - laryngomalacia
- Acute stridor - croup
- Inspiratory stridor - narrowing above glottis
- Expiratory stridor - narrowing of lower trachea
- Course crackles
- Airflow moves secretions or fluid in airways
- Usually clears when patient coughs or upper airway is suctioned - Fine crackles
- Sudden opening of small airways in lung deep breathing
- Heard with pulmonary fibrosis and atelectasis
- Pleural Friction Rub
Cardiac examination
- Chest wall overlying heart is known as precordium
- Insected, palpated, and auscultated for abnormalities
- Right ventricular hypertrophy causes an abnormal pulsation that can be seen and felt near lower margin of sternum, consistent with cor pulmonale (COPD) - Heave is abnormal pulsation felt over precordium
- Murmur is abnormal heart sound, often heard over precodium
- Murmurs produced by blood flowing through narrowed opening - Systolic murmurs caused by stenotic semilunar valves and incompetent AV valves
- Diastolic murmurs caused by stenotic AV valves or incompetent semilunar valves - Murmurs may also be created by rapid blood flow through normal valve in healthy people during heavy exercise
- Murmurs in babies may suggest cardiovascular abnormalities related to inadequate adjustment to extrauterine life
- S1: created by closure of AV valves
- S2: created by closure of semilunar valves
- S3: abnormal in adults and caused by rapid filling of stiff left ventricle - S4: caused by atrial “kick” of blood into noncompliant left ventricle - When patient has both S3 and S4 - gallop rhythm is present
- Pulsus paradoxes
- Drop in systolic pressure of 10 upon inspiration
- Due to Cardiac tamponade, severe asthma, COPD
- Pulsus tenderans
- Alternating strong and weak peripheral pulse
- Due to left ventricular dysfunction or heart failure
Abdominal Exam
- Abdomen inspected and palpated for distention tenderness
- Abdominal compartment syndrome - when intraabdominal pressure >20 mm Hg - An enlarged liver (hepatomegaly) is consistent with cor pulmonale
Examination of extremities
- Digital clubbing (not common) - seen in large variety of chronic conditions, congenital heart disease, bronchiectasis, various cancers, and interstitial lung diseases
- COPD does not have to have clubbing
- Digital cyanosis (acrocyanosis) - often sign of poor perfusion, hands and feet typically cool to touch in such cases
- Acrocyanosis occurs frequently in newborns,, usually disappears within 24 - 72 hours after birth
- Pedal edema
- Capillary refill
- Peripheral skin temperature