Patient Assessment pt.3 Part 3: Palpation, Percussion, Auscultation, Vital Signs, Lab Results

Patient Assessment

Overview

  • This section covers various methods used in patient assessment for respiratory care, including palpation, percussion, auscultation, measurement of vital signs, and interpretation of lab results.

Palpation

  • Definition: Touching the chest wall to assess the underlying structure and function.

  • Usage: Employed in selected patients to confirm or rule out problems suggested by history and initial examination findings.

Tracheal Deviation

  • Procedure: Place the index finger over the sternal notch and gently move from side to side.

  • Normal Finding: Trachea should be midline above the sternal notch.

Tracheal Alignment Abnormalities

  • **Causes of Deviation:
    *Shifts toward unaffected side:*

    • Pneumothorax

    • Pleural Effusion

  • Shifts toward affected side:

    • Fibrosis

    • Atelectasis

Chest Excursion

  • Definition: Symmetry of chest expansion.

  • Evaluation Method: Place hands over the patient's chest. The tips of the thumbs should move equally.

  • Normal Range: Approximately 3-5 cm from midline during inhalation.

Tactile Fremitus

  • Definition: Vibrations perceived over the chest wall by palpation.

  • Cause: Generated by gas flowing through thick secretions.

  • Prominence: Most noticeable between scapulae and near the sternum.

  • Increased in:

    • Consolidation (pneumonia)

    • Atelectasis

    • Pulmonary Edema

  • Decreased or Absent in:

    • Large pleural effusion

    • Large pneumothorax

    • Hyperinflation (air trapping)

Crepitus

  • Also Known As: Subcutaneous Emphysema.

  • Description: Coarse, crackling sensation (similar to "rice krispies") felt over skin when air escapes into subcutaneous tissue due to:

    • Blunt trauma

    • Stab or bullet wounds

    • Tracheostomy procedures

Percussion

  • Definition: Tapping on the patient’s chest to assess the density of underlying tissues (air, liquid, solid).

  • Procedure:

    • Place the distal portion of the middle finger of the non-dominant hand between ribs on the chest area to be examined.

    • Use the distal joint of the middle finger of the dominant hand to strike the finger on the chest and quickly withdraw.

    • Compare sounds systematically from top to bottom on both sides.

Systematic Percussion

  • Approach: Anterior and posterior systematic percussion pathways (Fig. 2-9).

Percussion Notes

  • **Types of Sounds: *Resonance:* Normal sound indicating healthy lung tissue.

    • Dullness: Indicates increased density caused by:

    • Atelectasis

    • Consolidation

    • Pleural Effusion

    • Fibrosis

    • Hyperresonance: Indicates air trapping caused by:

    • Hyperinflation (COPD)

    • Asthma

    • Pneumothorax

Diaphragmatic Excursion

  • Normal Range: 4-8 cm in adults.

  • Procedure for Assessment: Percuss over the diaphragm at maximum inhalation and exhalation, noting differences in sounds.

  • Abnormal Finding: Minimal excursion indicates hyperinflation (diaphragm is low and flat).

  • Skill Development: Requires practice and is a learned skill.

Auscultation

  • Definition: Listening to breath sounds using a stethoscope.

  • Ideal Position of Patient: Upright, breathing slowly and deeply through the mouth.

  • Technique Order: Auscultate in an orderly zig-zag fashion across anterior and posterior lung fields.

Order of Auscultating Lung Sounds

  • Normal Patterns: Normal (eupnea), tachypnea, bradypnea, hyperventilation, apneustic, Cheyne-Stokes, Kussmaul's type breathing, air trapping.

  • Normal Respiratory Rate: 12-20 breaths/minute.

  • Definitions of Patterns:

    • Tachypnea: >20 breaths/minute.

    • Bradypnea: <12 breaths/minute.

    • Hyperventilation: Sustained deep rapid breaths.

    • Apneustic: Sustained inspiratory effort.

    • Cheyne-Stokes: Alternating patterns of depth and brief periods of apnea.

    • Kussmaul's Breathing: Rapid, deep, and labored, common in diabetic ketoacidosis (DKA).

    • Air trapping: Difficulty in expiration commonly seen in emphysema.

Normal Breath Sounds

  • Types:

    • Bronchial (Tracheal): Harsh, hollow sounds auscultated over the trachea, indicating turbulent gas flow.

    • Vesicular: Normal sounds of gas rustling through small bronchioles and alveoli, primarily heard over the lung surface.

    • Bronchovesicular: Combination of bronchial and vesicular sounds.

Adventitious (Abnormal) Breath Sounds

  • Types:

    • Diminished Breath Sounds: Lower intensity; may indicate a patient moving less air, such as in obesity.

    • Fine Crackles (Rales): Indicate collapsed small airways/alveoli popping open during late inspiration; found in conditions like atelectasis, fibrosis, pulmonary edema.

    • Coarse Crackles: Series of low-pitched sounds suggesting air passing through mucus.; common in CHF, pneumonia, COPD.

    • Rhonchi: Snoring sounds indicating obstruction in large airways from secretions; may clear with coughing or suctioning.

    • Wheezing: High-pitched, musical sounds from bronchoconstriction; typical in asthma.

    • Pleural Friction Rub: Creaking sounds signifying inflamed pleura conditions like pleurisy/pneumonia.

    • Stridor: Loud crowing sound heard during inspiration due to upper airway obstruction (e.g., croup, epiglottitis).

Vocal Fremitus

  • Definition: Intensity and clarity of lung sounds perceived during phonation (speaking) over the chest.

  • Assessment Methods:

    • Bronchophony: Patient repeats “ninety-nine.”

    • Whispered Pectoriloquy: Patient whispers “1-2-3.”

    • Egophony: Patient says “ee”; abnormal if sounds like “ay.”

  • Indications: Decrease in vocal fremitus can signal obstructed bronchi, pneumothorax, or emphysema.

Vital Signs

Key Parameters

  • Pulse/Heart Rate: Rate, rhythm, strength.

  • Blood Pressure: Force exerted on arterial walls.

  • Respiratory Rate: Breaths per minute.

  • Body Temperature: Core body temperature in degrees Celsius or Fahrenheit.

  • SpO2: Peripheral oxygen saturation.

Pulse

  • Normal Adult Rate: 60-100 bpm.

  • Tachycardia: >100 bpm; first sign of hypoxemia.

  • Bradycardia: <60 bpm; indicative of heart failure or shock.

  • Measurement Method: Count beats in 15 seconds, multiply by 4.

Pulse Sites

  • Common Sites:

    • Radial (wrist)

    • Brachial (elbow)

    • Apical (heart)

    • Femoral (groin)

    • Carotid (neck)

Pulse Rhythm

  • Types: Regular or irregular.

  • Indicators of Irregularity: Inadequate blood flow or electrolyte imbalance.

Pulse Strength/Force

  • Normal Strength: Normally strong and throbbing.

  • Weak Contraction: Low volume indicates a weak, thready pulse.

  • Full, Bounding Pulse: Increased heart rate and volume indication.

  • Pulsus Paradoxus: Decrease during inspiration, often seen in severe asthma episodes.

Blood Pressure

  • Definition: Circulating blood pressure against arterial walls.

  • Normal Values:

    • Systolic: Top number

    • Diastolic: Bottom number

  • Measurement Tool: Sphygmomanometer

Blood Pressure Abnormalities

  • Hypertension: BP > 140/90 mmHg; indicates cardiac stress/hypoxemia.

  • Hypotension: BP < 90/60 mmHg; indicates poor perfusion, hypovolemia, CHF.

  • Orthostatic Hypotension: Quick drop in BP upon standing.

Factors Affecting Blood Pressure

  • Blood volume, viscosity, heart function, elasticity of blood vessels, resistance to blood flow.

Respiratory Rate

  • Normal Rate: 12-20 breaths/min.

  • Measure Method: Count breaths in 15 seconds or 30 seconds and multiply.

  • Best practice: Observe when patient is unaware to avoid altered breathing patterns.

Body Temperature

  • Normal: 37° C (98.6°F).

  • Hypothermia: Abnormally low temperature.

  • Hyperthermia: Abnormally high temperature.

  • Afebrile: Normal body temperature without fever.

  • Measurement Methods:

    • Oral (standard)

    • Axillary (one degree lower than oral)

    • Rectal (one degree higher than oral)

SpO2 (Oxygen Saturation)

  • Definition: Measure of peripheral oxygen saturation using a pulse oximeter.

  • Normal Values: 93-97% in adults.

SpO2 and PaO2 Correlation

  • Rule of Thumb:

    • SpO2 90% roughly correlates with PaO2 of 60 mmHg.

    • SpO2 80% corresponds to PaO2 of 50 mmHg.

    • SpO2 70% correlates to PaO2 of 40 mmHg.

  • Consideration: Applies primarily to patients under 60 years and without chronic CO2 retention.

Lab Results

Culture and Sensitivity Study

  • Purpose: Diagnose bacterial infection, select therapy, evaluate effectiveness.

  • Process: Collect single sputum sample in a sterile container.

  • Turnaround Time: 48-72 hours.

Complete Blood Count (CBC)

  • Definition: Frequent laboratory hematologic test providing essential information for the diagnosis and prognosis.

  • Components:

    • RBC (Red Blood Cells)

    • Hgb (Hemoglobin)

    • Hct (Hematocrit)

    • WBC (White Blood Cells)

    • Platelet Count

Red Blood Cell Count

  • Normal Value: 4-6 million/mm³.

  • Indications:

    • Polycythemia: High count due to chronic tissue hypoxemia (e.g., COPD).

    • Anemia: Low RBC count caused by blood loss or issues in RBC maturation.

Hemoglobin

  • Normal Value: 12-16 g/dL.

  • Indications: Low Hgb due to anemia; high due to polycythemia.

Hematocrit

  • Definition: Proportion of blood volume that is composed of red blood cells.

  • Normal Value: 40-50%.

White Blood Cell Count (WBC)

  • Normal Value: 5,000-10,000/mm³.

  • Indications:

    • Leukocytosis: Indicates bacterial infection.

    • Leukopenia: Indicates viral infections, certain cancers, sepsis.

Platelet Count

  • Normal Value: 150,000-400,000/mm³.

  • Importance: Essential for blood clotting.

Creatinine

  • Normal Value: 0.7-1.3 mg/dL.

  • Indications: Specifically indicates kidney function, elevated suggests kidney failure.

BUN (Blood Urea Nitrogen)

  • Definition: Measures the nitrogen amount from urea in blood, evaluating kidney function.

  • Normal Value: 8-25 mg/dL; increased BUN indicates kidney failure.

Electrolytes

  • Importance: Required for normal metabolic function; closely monitored in cases of fluid manipulation.

  • Common Monitoring: Sodium, potassium, chloride, calcium, bicarbonate.

Sodium (Na+)

  • Normal Value: 135-145 mEq/L.

  • Abnormalities:

    • Hyponatremia: Low sodium due to fluid loss (diuretics, vomiting).

    • Hypernatremia: High sodium typically due to kidney failure.

Potassium (K+)

  • Normal Value: 3.5-5.0 mEq/L.

  • Abnormalities:

    • Hypokalemia: Low potassium due to diuretics, hormone disorders.

    • Hyperkalemia: High potassium common in kidney failure.

Chloride (Cl-)

  • Normal Value: 80-100 mEq/L.

  • Abnormalities: Hypochloremia (low) and hyperchloremia (high), associated with various metabolic states.

Bicarbonate (HCO3)

  • Importance: Major component of acid-base balance, carrying CO2 in the blood.

  • Normal Value: 22-26 mEq/L.

Other Labs

  • D-Dimer: Test to rule out thrombus or embolus; should be around 0.5 mg/l; elevated levels indicate thromboembolic disease.

  • BNP (Brain Natriuretic Peptide): Normal <100 pg/mL rules out heart failure. Elevated levels cause decreased blood pressure and increased sodium/water excretion.

  • Troponins: Elevated levels indicate heart muscle injury.

  • Prothrombin Time (PT): Measures clotting time; INR values indicate therapy range and clotting tendencies.