RET 1024 Introduction to Respiratory Therapy

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RET 1024Introduction to Respiratory Therapy

• Module 4.0
• Bedside Assessment of the Patient

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Bedside Assessment of the Patient

• Examination of the Head and Neck
• Head
• Examine face for signs of respiratory problems
• Cyanosis
• Reduced oxygen content
• Pursed-lipped breathing
• COPD
• Nasal flaring
• Respiratory distress

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Bedside Assessment of the Patient

• Examination of the Head and Neck
• Head
• Cyanosis
• Reduced oxygen content

Central cyanosis lips, oral mucosa of mouth
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Bedside Assessment of the Patient

• Examination of the Head and Neck
• Neck
• Inspection and palpation of the neck
• Position of the trachea
• Jugular venous pressure (JVP)

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Bedside Assessment of the Patient

• Examination of the Head and Neck
• Neck
• Position of the trachea
• Normally in middle of neck
• Directly below the center of the suprasternal
  notch
• Shifts toward
• Collapsed lung
• Atelectasis
• Pneumonectomy
• Shifts away
• Increased air (tension pneumothorax)
• Increased fluid (pleural effusion
• Increased tissue (tumor)

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Bedside Assessment of the Patient

• Examination of the Head and Neck
• Neck
• Tracheal shift
• Pneumonectory

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Bedside Assessment of the Patient

• Examination of the Head and Neck
• Neck
• Tracheal shift
• Pleural effusion

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Bedside Assessment of the Patient

• Examination of the Head and Neck
• Neck
• Jugular Venous Pressure (JVP)
• Reflection of the volume of blood and pressure in
  right side of heart
• Right-sided heart failure
• Hypervolemia
• Estimated my examining the height of the blood
  column in the jugular veins

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Bedside Assessment of the Patient

• JVP
• Elevate head of patients bed to 45?
• Blood column should only be a few centimeters
  above the clavicle
• If venous pressure is elevated, neck veins may be
  distended as far as the jaw

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Bedside Assessment of the Patient

• JVP
• Distended Jugular VeinsThis patient with severe
  mitral stenosis is sitting upright. Note the
  distention of the jugular veins almost to the
  mandible, reflecting elevated pressures in right
  heart pressure.

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Bedside Assessment of the Patient

• JVP
• Nonpulsatile Distended Neck Veins in a patient
  with SVC syndrome

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Bedside Assessment of the Patient

• Examination Thorax and Lungs
• Inspection
• Palpation
• Percussion of the Chest
• Auscultation of the Lungs

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Bedside Assessment of the Patient

• Inspection
• Thoracic Configuration
• Anteroposterior (AP) diameter
• Increases slightly with age
• Increases prematurely with COPD

Barrel Chest associated with emphysema
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Bedside Assessment of the Patient

• Inspection
• Thoracic Configuration
• Pectus excavatum
• Pectus carinatum
• Scoliosis
• Kyphoscoliosis

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Bedside Assessment of the Patient

• Inspection
• Thoracic Configuration

Pectus carinatum
associated with restrictive lung defects
Pectus excavatum
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Bedside Assessment of the Patient

• Inspection
• Thoracic Configuration

Kyphosis
Scoliosis
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Bedside Assessment of the Patient

• Inspection
• Thoracic Configuration

Kyphoscoliosis
may produce sever restrictive lung disease as a
result of poor lung expansion
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Bedside Assessment of the Patient

• Inspection
• Breathing Patterns - Provide reliable clues about
  underlying pulmonary problem
• Rapid shallow breathing
• Loss of lung volume
• Atelectasis
• Pneumonia
• Pulmonary edema
• Pleural effusion
• Pneumothorax

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Bedside Assessment of the Patient

• Inspection
• Breathing Patterns - Provide reliable clues about
  underlying pulmonary problem
• Prolonged exhalation time (IE ratio ?)
• Airway obstruction intrathoracic
• Asthma
• Bronchitis
• Emphysema

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Bedside Assessment of the Patient

• Inspection
• Breathing Patterns - Provide reliable clues about
  underlying pulmonary problem
• Prolonged inspiratory time
• Upper airway obstruction extrathoracic
• Epiglotitis
• Croup
• Extrathoracic tumor

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Bedside Assessment of the Patient

• Inspection
• Breathing Patterns
• Increased work of breathing

Accessory muscles of ventilation
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Bedside Assessment of the Patient

• Inspection
• Breathing Patterns
• Increased work of breathing
• Retractions
• Sternal
• Intercostal
• Supraclavicular
• Subcostal

Sternal retractions
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Bedside Assessment of the Patient

• Palpation
• The art of touching the chest wall to evaluate
  underlying structure and function
• Vocal and tactile fremitus
• Thoracic expansion
• Assess skin and subcutaneous tissues of the chest

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Bedside Assessment of the Patient

• Palpation
• Vocal Fremitus vibrations created by the vocal
  cords during speech
• When the vibrations travel down the
  tracheobrochial tree, through the lung, and are
  felt on the chest wall, it is called tactile
  fremitus

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Bedside Assessment of the Patient

• Tactile Fremitus
• Ask patient to say ninety-nine or one, two,
  three or E while palpating the anterior,
  lateral, and posterior chest wall with either the
  dorsal or palmar aspects of the fingers, or the
  ulnar aspect of the hand

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Bedside Assessment of the Patient

• Tactile Fremitus
• May be
• Increased
• Atelectasis
• Pneumonia
• Decreased
• Pneumothorax
• Pleural effusion
• Emphysema
• Obesity
• Muscular
• Or Absent
• Pneumothorax
• Pleural effusion

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Bedside Assessment of the Patient

• Palpation
• Thoracic Expansion
• Normal chest wall expands symmetrically during
  inhalation
• Bilateral reduction in chest expansion
• Both lungs affected
• Neuromuscular diseases
• COPD
• Unilateral reduction in chest expansion
• One lung affected
• Lobar consolidation
• Atelectasis
• Pleural effusion
• Pneumothorax

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Bedside Assessment of the Patient

• Thoracic Expansion
• Posterior evaluation
• Place hands over the posterolateral chest
  thumbs extended and meeting at the T-8 vertebra
• Anterior Evaluation
• Place hands over the anterolateral chest thumbs
  extended along the costal margin toward the
  xiphoid process
• Instruct patient to exhale slowly and completely
• Extend the tips of the thumbs toward the midline
  until they are touching
• Grasp the chest securely and instruct the patient
  to take a full, deep breath
• Note the distance that the thumbs separate
• Normal Each thumb moves an equal distance of 3
  5 cm

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Bedside Assessment of the Patient

• Thoracic Expansion

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Bedside Assessment of the Patient

• Palpation
• Skin and subcutaneous tissues
• General temperature
• Condition of the skin
• Subcutaneous emphysema
• Air under the skin
• Produce a crackling sound and sensation when
  palpated called crepitus

Subcutaneous emphysema