Basic Assessment of Patient Cardiopulmonary system

1
bed side area inspection

• Oxygen
• Nebulizers
• Inhaler
• Peak flow meter
• Sputum pot

2
Mode of breathing

• SPONTANEOUS
• VENTILATOR
• TRACHEOSTOMY

3
Inspection patient

• Look ill?
• Weight loss
• Breathlessness
• Purse lip
• Cyanosis
• Using accessory muscles

4
Examining hands

• Nicotine stain
• Peripheral cyanosis
• Clubbing(bronchiatacsis,lung abcess,empyema,fibros
  ing alvelitis,asbestosis,cystic fibrosis)
• Wasting of small vessels of hand
• Tremor

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Pulse

• While palpating the pulse measure respiratory
  rate
• RR increased (asthma,pyrexia copd,,pnemonia,pulmon
  ary edema etc)
• RR Decreased(opium over dose,hypecapnia,hypothyrid
  ism,raised intracranial pressure)

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Eyes Anemia

• Mucus membrane of conjunctiva shows paller anemia
  nicely

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Face central cyanosis

• A blue discoloration of skin mucus membrane shows
  the hi concentration of deoxygenated hemoglobin

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Inspect of JVP

• Raised JVP above 4 cm mean
• Cor pulonale
• Tension pnemothorax
• Acute asthma
• PE
• SVC obstruction

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Chest inspection

• Shape
• Scar
• Swelling
• Marks
• Kyphosis

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Normal Shape of Chest

• It is eliptical,anterio-posterior diameter is
  lesser than its transverse diameter
• Normal Chest has two types
• 1. Asthenic Type( this type of narrow
  chest
• seen in thin and tall people)
• 2. Sthenic Type(This type of chest is
  broad and its
• vertical diameter is smaller ,is
  seen in short people)

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Abnormal forms of Chest

• Barrel (Shape(In this type the ribs are obliquely
  set and anterior-posterior diameter
• of chest is
  increased .The chest will look like in deep
  inspiration. Seen in
• emphysema
  patients.)
• Pigeon Shape (Sternum is prominent, the chest is
  triangular form)
• Funnel Shape(In this type there is depression in
  lower part of sternum, this has been seen
• in shoe
  makers)

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SYMETERY OF CHEST

• Normal chest will be symmetrical
• The asymmetrical Chest can present itself
  into two forms
• 1. Bulging
• 2. Retracted

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Bulging of Chest can be due to

• Plural Effusion
• Pneumothorax
• Kyphosis
• Massive Cardiomegaly
• Intrathorsic tumor
• Fracture and Mall union of ribs

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Retracted Type of Chest can be due to.

• Collapse and Fibrosis of Lungs
• Thickened Pleura
• Any Thoracoplasty Operation

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Chest Movement

• Can be Checked standing in the foot end of
  patient and see the chest is moving equally

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Type of Respiration

• Abdomino-thorcic
• (In Case of this type of respiration
  during inspiration the
• upper abdominal wall will protrude
  out.
• Thoraco- abdominal
• In this respiration the upper abdominal wall
  will hollow in.
• (Normal respiration in male abdomino- thoracic
  and in female it is thoraco-abdominal)

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Other Types of Respiration

• Cheyne Stokes Breathing
• In this the respiration gradually gets
  deeper and deeper and then there
• will or apnea.
• In following cases the Cheyne Stoke breathing
  available
• 1.Cardiac failure
• 2. Renal Failure
• 3. Severe Pneumonia
• 4. Increased Intracranial Pressure
• 5. Narcotic Drug Poising

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Acidotic Breathing(Kussamaul Breathing)

• This rapid and deep breathing seen in condition
  which leads to acidosis

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Palpation in Assessing Respiratory System

• Position of Trachea
• Place your 3 fingers(Index ,Middle and Ring)
  in a way that index and ring finger rest on the
  right and left sternoclavicular joints
  respectively while the middle finger is free to
  feel the gap between the sternomostoind muscle
  and trachea either side.
• The Pull of Trachea can be due to
• 1. Collapse Lung
• 2. Fibrosis Lung
• The Push of Trachea can be due to
• 1. Pneumothorax
• 2. Plural Effusion
• 3. Upper Midiastinal Tumor

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COUGH

• PRODUCTIVE
• NON PRODUCTIVE
• COLOR
• AMOUNT

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Breath sound check

• Anteriorly above the clavicle to 6 rib and
  laterally from the axilla to 8 rib

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Type of breath
Vesicular Bronchial
1. LOW pitch Soft sound 1. Loud Hi Pitch
2. Inspiration Longer 2. Expiration longer
3. NO PAUSE DURING Inspiration Expiration 3. Short Pause
4. Can be heard over all lung field except Anterior apex 4. Can be heard over Manubrium
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Normal Breath Sounds

• The bronchial breath sounds over the trachea has
  a higher pitch, louder, inspiration and
  expiration are equal and there is a pause between
  inspiration and expiration
• The breath sounds are symmetrical and louder in
  intensity in bases compared to apices in erect
  position. No adventitious sounds are heard.

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Abnormal

• Intensity of breath sounds, in general, is a good
  index of ventilation of the underlying lung. If
  the intensity increases there is more ventilation
  and vice versa. Breath sounds are markedly
  decreased in emphysema.
• Symmetry If there is asymmetry in intensity, the
  side where there is decreased intensity is
  abnormal.
• Any form of pleural of pulmonary disease can give
  rise to decreased intensity.

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Bronchial breathing anywhere other than over the
trachea

• Presence of bronchial breathing would suggest
• Consolidation
• Cavitations
• Complete alveolar atelectasis with patent airways
  
• Mass interposed between chest wall and large
  airways
• Tension Pneumothorax
• Massive pleural effusion with complete
  atelectasis of lung  
• (In all these conditions, there are no
  ventilation into alveoli and the sound that is
  heard originates from bronchi and is transmitted
  to the chest wall.)

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BRAETH SOUND (CONTNIUED)

• CLEAR
• CRACKLES
• RONCHI
• WHEESES
• DIMINISHED
• ABSENT

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Caution

• Make sure you warm the stethoscope before placing
  on patient's chest. Rub the metallic part of the
  stethoscope and warm it up.
• Don't make the patient hyperventilate by making
  them take deep breathes too many times. Give rest
  in between. Instruct the patient to take a deep
  breath only when you have your stethoscope on
  their chest.

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Palpation

• Position of Trachea
• Expansion of chest Anteriorly and posterior
• Vocal Fremitus
• Apex Beat
• Tenderness,Crepitaion

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Auscultation

• Intensity of breath
• Added Sound
• Character of Breath
• Vocal Resonance

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Character of Breathing

• Vesicular Breathing(passage of air through small
  bronchuls)
• 1. Expiration is shorter about ½ than
  inspiration
• 2. Inspiration is harsher than expiration
• 3. There is no pause between inspiration
  and expiration
• Bronchovasicular Breathing
• 1. Both Inspiration and expiration are harsh
• 2. Expiration is prolonged
• 3. There is short pause during inspiration
  and expiration

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Chest X-ray

• Quality of X-ray Film
• Position of patient
• Diaphragm
• Heart
• Mediastenum
• Hilar Shadow
• Lungs
• Skelton

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Left lung collapse .. left main bronchus plug
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Left plural effusion..consolidation
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Lt Side Plural Effusion
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Let Upper lobe tumor
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Left mediastinal peravortic tumor
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Pulmonary fibrosis and superimposed infection
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Right plural effusion because of metastasis
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Right middle lobe pneumonia
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Examination of CV System
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Examination

• Color
• Arterial Pulse
• BP
• Neck vein
• Pericardium

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Examination Of Pulse

• Rate
• Rhythm
• Volume
• Tension
• Character
• Blood Vessel Wall
• Comparison of pulse

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Method of Auscultation

• Mitral Area Normally it is over 5th
  intercostals space cm medial to left
  midclavicular line
• Tricuspid Area
• It is near the lower end of left
  border of sternum in 4th and 5th intercostals
  space.
• Pulmonary Area Near the left border of sternum
  left 2nd intercostals space
• Aortic Area
• There are two aortic areas, First is over
  right second intercostals space near the sternum
  second is left of sternum over third intercostals
  space

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Heart Sounds

• Normally two sounds
• 1st Heart sound (Systolic Sound)
• 2nd Heart Sound (Diastolic Sound)
• Correspond the sound Lub dub
• Can be irregular in (Extra systole, AF,A
  Fib, Ectopic beats)

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Intensity of 1st Heart Sound

• Increased
• MS,Systemic HTN,Tachycardia
• Decreased
• Rymetic Carditis,MVR,Ist degree heart Block

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Intensity of 2nd Heart Sound

• Two components aortic, and pulmonary so related
  to these can cause of increased and decreased
  intensity

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Third Heart Sound

• Physiological
• 1. Children
• 2. Pregnancy
• Pathologic
• 1. MI
• 2. Heart failure
• It occurs 0.15 sec after the 2nd heart sound

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MURMURS

• Functional Murmur
• 1. Not associated with any structural
  heart disease
• (a) Hemic Murmur (b) Cardio
  respiratory Murmur

• Organic Murmur
• 1. Not associated with any structural
  heart disease
• (a) Forward Obstruction (b) Backward
  leakage

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Characteristics of Murmurs
Organic Murmur Functional Murmur
Intensity increases after exercise Disappears after exercise
Radiates to other areas Does not radiate
Thrill may be present Thrill is never present
Intensity change with different posture and respiration Intensity does not change with change of posture and or respiration
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Causes of Systolic murmur

• AVS
• MVR
• TR
• PS
• VSD

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Diastolic Murmur

• AVR
• MS
• PR
• TS

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Grading of Murmur

• Grade 1 very Faint
• Grade 2 Medium intensity
• Grade 3 Loud No thrill
• Grade 4 Loud with thrill
• Grade 5 very loud
• Grade 6 Audible without stethoscope

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SHAMS ALI SHAH RT PSCCQ