Bedside Assessment of the Patient — Vocabulary Flashcards (Video)

Learning Objectives (1 of 10)

• Describe why patient interviews are necessary and the appropriate interview techniques.
• Differentiate social from personal space and how these spaces are used during an interview.
• List four influential factors affecting communication between the RT and the patient.
• Differentiate between signs and symptoms.

Learning Objectives (2 of 10)

• List the five neutral questions used to elicit information about a patient’s symptoms.
• Differentiate between dyspnea and breathlessness.
• Recall the three factors that generate the perception of breathing.
• List the four interview questions used to assess the degree and context of dyspnea in patients.

Learning Objectives (3 of 10)

• Recall the four factors necessary to generate an effective cough.
• Identify five important cough characteristics that the RT is responsible for monitoring.
• Describe the differences between infected and non-infected sputum.
• Explain the differences between massive and non-massive hemoptysis and their associated clinical conditions.

Learning Objectives (4 of 10)

• Explain the differences between pleuritic and non-pleuritic chest pain and their associated clinical conditions.
• Define the temperature threshold for fever and describe the different sources producing fever.
• Describe the different characteristics of pedal edema and the diseases associated with it.

Learning Objectives (5 of 10)

• List the five major categories of patient information gleaned from reviewing the medical record.
• Calculate smoking history in pack-years.
• Describe the four general steps taken during the physical examination of a patient.
• Define the term sensorium and list the four criteria used to determine its presence.

Learning Objectives (6 of 10)

• List the five elements that constitute basic vital signs and recite the normal parameters for each variable.
• Identify the seven anatomic sites where a pulse pressure can be palpated during a physical exam.
• Define hypertension and describe the three categories used to describe it.
• Define hypotension and explain how it differs from shock.

Learning Objectives (7 of 10)

• Describe the steps required to measure blood pressure using a blood pressure cuff and stethoscope.
• Describe how examination of the head and neck can reveal signs associated with chest diseases such as COPD and CHF.
• Describe common signs of increased work of breathing gleaned from physical exam of the neck and chest.

Learning Objectives (8 of 10)

• Differentiate the two archetypal breathing patterns associated with restrictive versus obstructive lung disease.
• Describe the five abnormal breathing patterns associated with neurological disease and injury.
• Describe how lung hyperinflation and diaphragmatic dysfunction are assessed during physical examination of the chest.

Learning Objectives (9 of 10)

• Identify the three normal breath sounds.
• Differentiate the two main adventitious breath sounds and relate them to common pulmonary disease in which they occur.
• Define the point of maximal impulse (PMI) and describe how it is affected in common cardiopulmonary diseases.
• Define the four common heart sounds and describe the underlying cardiac mechanisms that generate them.

Learning Objectives (10 of 10)

• Explain how abdominal dysfunction can negatively impact breathing and promote lung disease.
• Describe the four signs of cardiopulmonary disease that can be gleaned from examining the extremities.

Introduction (1 of 3)

• Clinical assessments help physicians make decisions regarding when to initiate, change, or discontinue therapy; depend upon accurate assessment.
• The physician is responsible, but RTs participate in clinical decision making.
• Bedside assessment: process of interviewing and examining patient for signs and symptoms of disease and evaluating the effects of treatment.

Introduction (2 of 3)

• 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 and physical examination.

Introduction (3 of 3)

• 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 to 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 is establishing rapport.
• Factors affecting communication between the RT and the patient:
  • 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 (1 of 2)

• 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.

Structure and Technique for Interviewing (2 of 2)

• Common questions to ask for each symptom:
  • When did the symptom start?
  • How severe is it? (rating on a scale of 1-10)
  • Where on the body is it? (important for chest pain)
  • What seems to make it better or worse?
  • Has it occurred before? (If so, how long did it last?)
• Note: the best interview techniques are worthless if the interviewer lacks knowledge about pathophysiology and characteristic symptoms of common cardiopulmonary diseases.

Common Cardiopulmonary Symptoms

• Dyspnea: sensation of breathing discomfort by patient (subjective); most important symptom RT is called upon to assess and treat.
• Breathlessness: sensation of unpleasant urge to breathe.
• Breathlessness can be triggered by acute hypercapnia, acidosis, and hypoxemia.

Positional Dyspnea (1 of 2)

• Orthopnea: dyspnea triggered when the patient assumes the reclining position; common in CHF, mitral valve disease, and superior vena cava syndrome.
• Platypnea: dyspnea triggered by assuming the upright position; typically after pneumonectomy or in hepatopulmonary syndrome; sometimes observed during hypovolemia and in some neurologic diseases.

Positional Dyspnea (2 of 2)

• Orthodeoxia: oxygen desaturation on upright position; accompanies platypnea.
• Trepopnea: when lying on one side relieves dyspnea; usually associated with CHF or pleural effusion.

Language of Dyspnea

• RT should categorize each sensation by an aspect of breathing: inspiration, expiration, respiratory drive, or lung volume.
• Ask about quality and characteristics; may provide insight into etiology.
• Examples:
  • Asthma: chest tightness.
  • Interstitial lung disease: increased WOB, shallow breathing, gasping.
  • CHF: feeling of suffocation.
• Cardiopulmonary disease often presents with several unpleasant breathing sensations simultaneously.

Assessing Dyspnea During an Interview (1 of 2)

• Pay attention to whether the patient can speak in full sentences.
• If severe dyspnea, the initial interview should be curtailed and treatment started promptly.
• Questions should be brief, focusing on quality and intensity and circumstances of onset.
• Assessment should correspond with gross examination of breathing pattern.

Assessing Dyspnea During an Interview (2 of 2)

• In chronic cardiopulmonary disease, a detailed history should cover four major areas:
  • What activities of daily living (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.
  • Recall when dyspnea first began and how it has evolved over time.

Psychogenic Dyspnea

• Panic disorders and hyperventilation.
• Psychogenic hyperventilation syndrome: normal cardiopulmonary function but intense dyspnea and suffocation.
• May co-occur with chest pain, anxiety, palpitations, paresthesias.
• Anxiety often accompanied by breathlessness; RT should approach hyperventilation as if it could have a pathogenic basis.
• Consider Vital signs, ABG, and possibly 12-lead ECG.

Cough (1 of 2)

• Most common, nonspecific symptom in pulmonary disease.
• Cough receptors in airways are stimulated by inflammation, mucus, foreign material, or noxious gases.
• Often impaired in: cardiopulmonary, neurologic or neuromuscular diseases; after upper abdominal or thoracic surgery; after trauma due to pain.

Cough (2 of 2)

• RT should note cough characteristics:
  • Dry vs. productive; acute vs. chronic; timing (day/night).
• A chronic cough is defined as lasting 8 weeks or longer.

Causes of Chronic Cough

• Upper airway cough syndrome (UACS) – formerly known as postnasal drip
• Asthma
• Gastroesophageal reflux
• Chronic bronchitis related to cigarette smoking
• ACE-1 Cough
• Nonasthmatic eosinophilic bronchitis

Sputum Production

• Mucus from tracheobronchial tree not contaminated by oral secretions = phlegm
• Mucus from lower airways and expectorated = sputum
• Sputum with pus cells = purulent
• Fetid sputum = foul-smelling
• Recent changes in sputum color, viscosity, or quantity may indicate infection

Hemoptysis

• Coughing up blood or blood-streaked sputum from the lungs.
• Massive: >300 ext{ mL} of blood excreted over 24 ext{ hours}.
• Common causes: bronchiectasis, lung abscess, TB.
• Distinct from hematemesis (vomiting blood from GI tract).
• Nonmassive: common causes include infection of airway, TB, trauma, pulmonary embolism.

Hematemesis

• Blood vomited from the gastrointestinal tract.
• Often occurs with GI disease.
• Vomiting can stimulate the cough reflex.
• Sometimes difficult to differentiate the origin of bleeding.

Chest Pain

• Pleuritic chest pain: lateral/posterior location; sharp; worsens with deep breathing; seen in pneumonia and pulmonary embolism.
• Nonpleuritic chest pain: center of chest; may radiate to shoulder or arm; not affected by breathing; causes include angina, GERD, esophageal spasm, chest wall pain, gall bladder disease.

Fever

• Temperature > 38.3^ ext{C} or 101^ ext{F}.
• May occur with simple viral upper airway infection or with pneumonia, TB, and some cancers.
• Causes increased metabolic rate, oxygen consumption, and carbon dioxide production.
• Particularly dangerous in severe chronic cardiopulmonary disease due to risk of acute respiratory failure.

Pedal Edema

• Swelling of lower extremities, often due to heart failure.
• Two subtypes: 1) pitting edema; 2) weeping edema (small fluid leak at pressure site).
• Chronic hypoxemic lung disease can lead to right heart failure (cor pulmonale) due to pulmonary hypertension.

The Medical Record and Medical History (1 of 2)

• RT's first priority: ensure respiratory care procedures are supported by a physician order that is current, clearly written, and complete.
• Then review patient’s medical record for current medical problems.

The Medical Record and Medical History (2 of 2)

• Familiarizes clinician with patient’s condition.
• Reviewing chart components:
  • Chief complaint (CC) / history of present illness (HPI): explains current medical problems.
  • Past medical history (PMH).
  • Smoking history (in pack-years): Packs per day × number of years smoked.
  • Family, social, environmental history: genetic/occupational links and current life situation.
  • Review of systems (ROS).
  • Advance directive.

ext{Pack-years} = ( ext{packs per day}) imes ( ext{years smoked})

Physical Examination

• Essential for evaluating the patient’s problem and determining ongoing effects of therapy.
• Four steps: Inspection, Palpation, Percussion, Auscultation.

General Appearance

• Assessed during the first few seconds of the encounter.
• Indicators include: level of consciousness, facial expression, level of anxiety/distress, body positioning, personal hygiene.

Level of Consciousness

• Sensorium: orientation to time, place, person, and situation (oriented × 4).
• Reflects brain oxygenation status; affected by poor cerebral blood flow (hypotension).
• If patient is not alert, use a standard rating scale to describe level of consciousness.

Vital Signs (VS)

• Vital signs are easy to obtain and provide useful information about current health status.
• VS provide early clues to adverse reactions to treatment.
• Most frequent vital signs are: temperature, pulse rate, respiratory rate, and blood pressure.

Body Temperature

• Normal: 37.0^ ext{C}} (often cited as 98.6° F).
• Hyperthermia or fever: increased temperature.
• Hypothermia: decreased temperature.
• Measurement sites: mouth, axilla, ear, rectum; rectal temperature is closest to core.

Pulse Rate (1 of 2)

• Evaluate rate, rhythm, and strength.
• Radial artery is the most common palpation site.
• Normal adult pulse: 60-100\,\text{beats/min}.
• Tachycardia: > 100\,\text{beats/min}.
• Bradycardia: < 60\,\text{beats/min}.
• Common causes include: exercise, fear, anxiety, low BP, anemia, fever, hypoxemia, hypercapnia; some medications.

Pulse Rate (2 of 2)

• Spontaneous ventilation can influence pulse amplitude.
• Slightly decreased pulse pressure with each inspiratory effort.
• Pulsus paradoxus: significant drop in pulse strength (>10\,\text{mmHg}) during inspiration; common in acute obstructive disease (e.g., asthma attack).
• Pulsus alternans: alternating strong and weak pulses; suggests left-sided heart failure; not typically respiratory.

Respiratory Rate (RR)

• Resting adult RR: 12-18\,\text{breaths/min}.
• Tachypnea: > 20\,\text{breaths/min}; associated with exertion, fever, hypoxemia, hypercarbia, metabolic acidosis, anxiety, edema, pain.
• Bradypnea: < 10\,\text{breaths/min}; may occur with TBI, MI, hypothermia, anesthesia, opioids, overdose.

Arterial Blood Pressure (1 of 2)

• Systolic pressure: peak force during LV contraction; 90-140\,\text{mmHg}.
• Diastolic pressure: force during LV relaxation; 60-90\,\text{mmHg}.
• Pulse pressure: difference between systolic and diastolic; normal 30-40\,\text{mmHg}.
• Hypertension: BP persistently greater than 140/90\,\text{mmHg}.
• Hypotension: Systolic < 90\,\text{mmHg} or mean arterial pressure < 65\,\text{mmHg}.

Arterial Blood Pressure (2 of 2)

• Shock: inadequate delivery of O2 and nutrients relative to metabolic demand; treated with fluids, blood products, and/or vasoactive drugs.
• Types listed: cardiogenic, hypovolemic, septic, anaphylaxis; plus postural hypotension and syncope.

Examination of the Head and Neck (1 of 2)

• Head: nasal flaring (infants) indicates respiratory distress and increased WOB; central cyanosis (cyanosis of oral mucosa) indicates respiratory failure due to hypoxemia; pursed-lip breathing common in COPD.

Examination of the Head and Neck (2 of 2)

• Neck: inspect and palpate to assess tracheal position (may shift away from midline in some thoracic disorders); JVD seen in CHF and cor pulmonale; enlarged neck lymph nodes may indicate infection or malignancy.

Examination of the Thorax and Lungs (1 of 5)

• Inspection focuses on: thoracic configuration, expansion, and pattern/effort of breathing; respect patient modesty.

Examination of the Thorax and Lungs (2 of 5)

• Thoracic configuration: AP diameter normally less than transverse; barrel chest indicates emphysema; other shapes include:
  • Pectus carinatum: protruding sternum.
  • Pectus excavatum: sunken sternum, can cause restrictive defect.

Examination of the Thorax and Lungs (3 of 5)

• Thoracic configuration continued: kyphosis (posterior curvature), scoliosis (lateral curvature), kyphoscoliosis (combo) may cause restrictive defects.

Examination of the Thorax and Lungs (4 of 5)

• Thoracic expansion: diaphragm is primary breathing muscle; chest wall expansion should be symmetric when assessed anteriorly and posteriorly.
• Diseases affecting expansion of both lungs cause bilateral reduction; commonly seen in neuromuscular disorders and COPD.

Examination of the Thorax and Lungs (5 of 5)

• Unilateral reduction in chest expansion suggests localized disease (one lung or part of lung).

Breathing Pattern and Effort (1 of 9)

• Abnormal breathing patterns fall into two broad categories:
  1) Related to cardiopulmonary or chest wall diseases increasing work of breathing (WOB).
  2) Related to neurologic disease.

Breathing Pattern and Effort (2 of 9)

• Common causes of increased WOB:
  • Narrowed airways (e.g., COPD, asthma).
  • Stiff lungs (e.g., ARDS, cardiogenic pulmonary edema).
  • Stiff chest wall (e.g., ascites, generalized edema, pleural effusions).
• Retractions as a sign of very increased WOB: intercostal, supraclavicular, subcostal retractions; tracheal tugging (downward movement of thyroid cartilage during inspiration).

Breathing Pattern and Effort (3 of 9)

• Two typical abnormal patterns:
  1) Rapid, shallow breathing.
  2) Brief inspiratory phase with prolonged exhalation and pronounced abdominal contraction.
• These patterns provide clues to the underlying pulmonary problem.

Breathing Pattern and Effort (4 of 9)

• Additional patterns:
  • Apnea: no breathing; causes include cardiac arrest, narcotic overdose, severe brain trauma.
  • Apneustic breathing: deep, gasping inspiration with brief, partial expiration; causes: upper medulla/pons damage, stroke, trauma; sometimes with severe hypoxemia.
  • Ataxic breathing: completely irregular with variable apnea periods; causes: medulla damage.
  • Asthmatic breathing: prolonged exhalation with abdominal recruitment; causes: airway obstruction.
  • Biot: clustering of rapid, shallow breaths with apnea; causes: medulla or pons damage, stroke, trauma, intracranial hypertension.

Breathing Pattern and Effort (5 of 9)

• Other patterns:
  • Cheyne-Stokes: irregular breathing with alternating deep/shallow breaths and apnea; causes: bilateral brain damage, CHF, encephalopathy.
  • Kussmaul: deep and fast respirations; causes: metabolic acidosis.

Breathing Pattern and Effort (6 of 9)

• Paradoxical breathing:
  • Abdominal paradox: abdomen moves inward on inspiration and outward on expiration; cause: diaphragmatic fatigue or paralysis.
  • Chest paradox: chest wall moves in on inspiration and out on expiration; causes: chest trauma with rib/sternal fractures; high spinal cord injury with intercostal paralysis.

Breathing Pattern and Effort (7 of 9)

• Periodic breathing: oscillation between rapid/deep breaths and slow/shallow breaths without apnea; causes: severe bilateral brain damage or CHF with prolonged circulation time, or encephalopathy.

Breathing Pattern and Effort (8 of 9)

• Additional patterns: apnea, apneustic, ataxic, Biot, Cheyne-Stokes, Kussmaul, paradoxical, periodic (continued).

Breathing Pattern and Effort (9 of 9)

• Summary: multiple abnormal patterns; pattern analysis aids in diagnosing underlying pathology.

Diaphragmatic Fatigue

• Found in many chronic/acute pulmonary diseases.
• Signs of acute fatigue include tachypnea, diaphragm/rib cage muscle alternation (respiratory alternans), abdominal paradox with fatigue, Hoover sign.

Chest Palpation (1 of 2)

• Palpation evaluates underlying structure/function by touch.
• Vocal and tactile fremitus increased with pneumonia/atelectasis (consolidation); decreased with emphysema, pneumothorax, pleural effusion.

Chest Palpation (2 of 2)

• Chest expansion: bilateral reduction seen in neuromuscular disorders and COPD; unilateral reduction with pneumonia or pneumothorax.
• Crepitus may occur due to subcutaneous emphysema, indicating air leaks into subcutaneous tissues.

Percussion Over Lung Fields

• Systematic evaluation by comparing comparable areas on both sides.
• Percussion resonance described as normal, increased, or decreased.
• Decreased resonance suggests pneumonia or pleural effusion (consolidation).
• Increased resonance suggests emphysema or pneumothorax (air).

Auscultation of the Lungs (1 of 7)

• Tracheal breath sounds: heard over trachea; loud with expiratory component equal to or longer than inspiratory.
• Bronchovesicular breath sounds: around sternum; softer and lower in pitch.
• Vesicular breath sounds: over lung parenchyma; soft and low-pitched.

Auscultation of the Lungs (2 of 7)

• Normal breath sounds: generated by turbulent flow in larger airways; altered by travel through lung periphery and chest wall; normal tissue acts as a low-pass filter.

Auscultation of the Lungs (3 of 7)

• Adventitious lung sounds: two types
  • Discontinuous: crackles (intermittent, short duration).
  • Continuous: wheezes; stridor when heard over upper airway.

Auscultation of the Lungs (4 of 7)

• Bronchial breath sounds: abnormal if heard over peripheral lung regions; replace vesicular sounds when lung tissue density increases.
• Diminished breath sounds: occur when sound intensity is reduced at source or transmission is reduced due to COPD/asthma.

Auscultation of the Lungs (5 of 7)

• Wheezes: indicate airway obstruction.
• Monophonic wheeze: one airway affected; Polyphonic wheeze: many airways involved.

Auscultation of the Lungs (6 of 7)

• Stridor: upper airway compromise; chronic stridor (laryngomalacia); acute stridor (croup).
• Inspiratory stridor suggests upper airway narrowing above the glottis; expiratory stridor suggests lower tracheal narrowing.

Auscultation of the Lungs (7 of 7)

• Coarse crackles: airflow movement with secretions or fluid; usually clears with coughing or suctioning.
• Fine crackles: opening of small airways on deep inspiration; seen in pulmonary fibrosis and atelectasis.
• Pleural friction rub: rough, rubbing sound from pleural surfaces.

Cardiac Examination (1 of 4)

• Precordium: chest wall over the heart; inspected, palpated, auscultated for abnormalities.
• Right ventricular hypertrophy can cause abnormal pulsation near the lower margin of the sternum; associated with cor pulmonale (COPD).

Cardiac Examination (2 of 4)

• Heave: abnormal pulsation felt over precordium.
• Murmur: abnormal heart sound caused by turbulent flow; may be due to narrowed opening.
• Systolic murmurs: due to stenotic semilunar valves or incompetent AV valves.

Cardiac Examination (3 of 4)

• Diastolic murmurs: due to stenotic AV valves or incompetent semilunar valves.
• Murmurs may also be created by rapid flow through normal valves during heavy exercise.
• Murmurs in infants may indicate cardiovascular abnormalities related to adaptation to extrauterine life.

Cardiac Examination (4 of 4)

• S1: closure of AV valves.
• S2: closure of semilunar valves.
• S3: abnormal in adults; due to rapid filling of a stiff left ventricle.
• S4: due to atrial kick into a noncompliant left ventricle.
• Gallop rhythm when S3 and S4 are both present.

Abdominal Exam

• Abdomen inspected and palpated for distention and tenderness.
• Abdominal compartment syndrome: intraabdominal pressures > 20\, \text{mmHg}.
• Enlarged liver (hepatomegaly) is consistent with cor pulmonale.

Examination of Extremities (1 of 2)

• Digital clubbing: not common; seen in diverse conditions including congenital heart disease, bronchiectasis, some cancers, and interstitial lung diseases.

Examination of Extremities (2 of 2)

• Digital cyanosis (acrocyanosis): signs of poor perfusion; hands and feet cool to touch.
• Acrocyanosis common in newborns; usually disappears within 24-72\, \text{hours} after birth.
• Pedal edema; capillary refill; peripheral skin temperature.