Physical Assessment of the Pulmonary Patient

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Physical Assessmentof the Pulmonary Patient

• Information Gathering for Clinical Decision Making

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What is physical assessment?

• A process of collecting and evaluating subjective
  and objective information, which allows the
  clinician (RCP) to understand the patients
  current condition, and to detect problems in
  order to develop and initiate the appropriate
  plan of action.

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What else can it do?

• When used continuously to monitor the patients
  progress, it can be used to evaluate the
  patients response to the respiratory care
  regimen to suggest modifications to current Rx,
  to provide a basis for documentation of the care
  given, and to assure patient safety during the
  course of Rx.

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Step 1 Patient Record

• Biographical data gender, age, ethnicity,
  occupation, education, etc
• Chief complaint (C/C C.C.) why did the patient
  seek medical attention
• Hx of present illness symptoms experienced, time
  of onset, severity, duration, aggravating and
  alleviating factors

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Step 1 Patient Record

• Past medical Hx prior hospitalization, injuries,
  surgeries, allergies, medications, past medical
  problems, ADL,etc
• Social Hx familial or genetic patterns of
  disease, use of ETOH, tobacco, nonprescription
  medications, stress
• Occupational/Environmental Hx exposure to
  potential hazards or diseases at home or work

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Step 2 Physical Examination

• Vital Signs (BP, HR, RR, T)
• - Provides immediate information about the
  general health of the patient
• Neurological evaluation
• - To determine the LOC, sensorium
• - To determine the patients orientation to
  time, place, and person
• - To evaluate protective reflexes
• - To evaluate gross motor/sensory function

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Step 2 Physical Examination

• Inspection, palpation, percussion, auscultation
• - Looking, feeling, thumping, listening
• Cardiac Evaluation
• - EKGs, inline BP monitoring, indwelling
  catherization
• Laboratory
• - PFT, blood chemistry, chest x-ray

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Step 4 Inductive Thinking

• Collect, interpret, evaluate, and analyze
• Organize into problem areas, label, and sort from
  high to low priority of care
• Provide support for each problem area
• Develop a plan of action for each problem area
• Jus do it
• Reevaluate and adjust

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Vital Signs 101

• Blood Pressure
• Pressure exerted within the walls of blood
  vessels during systole and diastole
• Measuring
• Direct
• Arterial catherization with indwelling arterial
  or venous catheter (20 to 16 gauge)
• Radial, brachial, and femoral sites
• Indirect
• Using blood pressure cuff and manometer
• Auscultory, palpatory, doppler

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Blood pressure

• Measure
• Systolic pressure
• during contractions
• Diastolic pressure
• between contractions
• Pulse pressure systolic diastolic
• Mean arterial pressure
• systolic (2 x diastolic) / 3
• diastolic ? (pulse pressure)

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Physiological Factors that affect BP

• HR
• Stroke volume
• Inotropy-strength of contraction
• Vasoaction-constriction/dilation
• Fluid volume
• Age
• Mental and physical stress

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Other factors that affect BP

• Obesity
• Exercise
• Emotions
• Hemorrhage
• Shock
• Stroke
• MI
• Toxemia

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Heart rate

• Palpation
• radial, ulnar, brachial, femoral, carotid, pedal
  arteries
• Auscultation
• Apical
• HR monitor
• EKG
• Pulse oximetry

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Heart rate

• Measure
• Rate beats per minute
• Rhythm regular, irregular
• Strength strong, bounding, weak, feeble,
• thready

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Heart rate

• Factors that affect HR
• Gender
• Age
• Exertion
• Eating and drinking
• Body position
• State of health
• Awake vs. at rest or asleep

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Respiratory rate

• Measure
• rate, rhythm, depth _at_ rest
• visual, palpation, auscultation
• Premature infant 40-90/min
• Newborn (term) 30-50
• Child (2-12yrs) 20-30
• Adult 12-20

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Respiratory rate

• Terminology
• Eupnea normal rate
• Bradypnea lt12 breaths/min
• Tachypnea gt20 breaths/min
• Hypopnea shallow, small tidal volumes (TV)
• Hyperpnea deep, large TVs
• Dyspnea subjective feeling of shortness of
  breath (SOB)

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Temperature

• Measurement varies to body area and time of day
• Orally 37C
• Rectally 37.5C
• Ancillary 36.5C
• 37C 98.6F
• conversion
• 1.8C 32 F

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Temperature

• Temperature ? with fever, exercise
• Body attempts to ? core T by shivering
• Body attempts to ? core T by sweating
• Body T is a balance between heat production and
  heat loss
• 85 heat loss through skin
• 15 heat loss through feces, urine
• Thermoregulator hypothalamus

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Neurological Evaluation

• Asking questions
• Do you know where you are? Place? Who you are?
  What time and day it is?
• What are your symptoms?
• Evaluating sensorium or level of consciousness
  (LOC)
• Evaluate protective reflexes gag, cough, swallow

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Neurological Evaluation

• Alert
• normal mental state
• orientated to time, place, and person
• responds readily to verbal commands
• responses are appropriate and relevant
• movements are purposeful

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Neurological Evaluation

• Obtunded (drowsy)
• appears sleepy but will respond slowly to verbal
  commands or physical stimuli
• Stuporous or lethargic
• appears unconcious or very sleepy
• will respond to strong verbal commands or
  physical stimuli

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Neurological Evaluation

• Comatose
• unconscious and unresponsive to verbal commands
• may respond to painful stimuli by posturing
  and/or grimacing no purposeful movements
• decorticate arms and legs tend to contract with
  stimuli, e.g., suctioning
• decerebrate arms and legs extend with stimuli
• flaccid no response to stimuli and no movement

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Neurological Evaluation

• Other
• Emotional state
• does the patient appear to
• calm, restless, excited, depressed, distressed
• Complaints of dyspnea
• subjective feeling of SOB
• mild, moderate, or severe respiratory distress
• at rest
• lying flat, require pillows, or tripoding
• can converse easily, with effort, or unable to
  talk
• upon exertion

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Inspection

• General appearance
• body mass
• normal
• obese
• thin
• cachetic (emaciated, undernourished)
• skin color (nail beds, lips, mucus membranes)
• pink
• ashen, gray, dusky
• blue
• diaphoresis
• clubbing of the digits

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Inspection

• Chest configuration
• normal
• barrel
• pectus excavatum (funnel chest)
• pectus carinatum (pidgeon chest)
• scoliosis
• kyphosis
• kyphoscoliosis
• lordosis

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Inspection

• Chest movement
• normal
• active diaphragm, no accessory muscle use at rest
• IE ratio or 12 or 13
• equal, bilateral chest expansion
• abnormal
• accessory muscle use
• IE ratio lt 12, e.g., 16 or longer E to I
• long expiratory phase
• distended jugular veins
• increased A-P diameter, barrel chest

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Inspection

• Breathing patterns
• abnormal
• apnea
• Cheyne-Stokes
• ? ICP, CHF, renal failure, meningitis, drug
  overdose
• Biots
• spinal meningitis, CNS conditions
• Kussmaul
• metabolic acidosis, esp. diabetic ketoacidosis
• Apneustic
• lesion in respiratory center

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Inspection

• Cough
• evaluate quality, character, and frequency
• quality and character of the cough
• effective or strong
• capable of clearing airways
• ineffective or weak
• pain, poor motivation
• other descriptors
• hoarse, brassy, barking, hacking

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Inspection

• frequency of cough
• acute sudden onset, usually short course
• chronic daily, ongoing, long course
• paroxysmal sudden, periodic, prolonged episodes

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Inspection

• Sputum
• normal health adult
• 95 H2O, 2 lipoprotein, 1 carbohydrate, DNA,
  trace lipids
• watery, mucoid (clear, white, translucent
• abnormal sputum characteristic/color
• mucopurulent (light to medium yellow)
• purulent (dark yellow to green)
• hemoptysis (red)
• frothy (clear, white, pink)
• tenacious (thick)

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Inspection

• sputum consistency
• thin or watery
• thick, tenacious, or viscous
• sputum production
• scant (just noticeable on tissue)
• small (1 teaspoon)
• moderate (2 tablespoons)
• large or copious (gt2 tablespoons)

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Palpation

• Placement of palms on the lateral aspect of the
  chest wall to evaluate movement and uniform
  expansion
• Feel for presence of
• tactile or vocal fremitus (palpable rhonchi)
• subcutaneous emphysema (crepitation)
• tenderness
• pedal edema
• skin temperature of extremities
• warm (normal)
• hot (fever)
• cold or clammy (hypothermia or hypoperfusion)

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Percussion

• Purpose to assess sound intensity and pitch or
  resonance
• Tapping the surface of the chest
• mediate tapping one finger upon another that is
  located on the chest
• immediate tapping directly on the chest with one
  finger

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Percussion

• ? resonance (dull or flat sound)
• consolidation (lobar pneumonia or tumors)
• fluid filled (pulmonary edema)
• pleural effusion (fluid between parietal and
  visceral layers)
• atelectasis (deflated lung units)
• obese (too much tissue, ? lung volumes)
• hemothorax (blood in chest cavity)

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Percussion

• ? resonance or hyperresonant
• hyperinflated lungs (emphysema)
• pneumothorax
• Diaphragmatic excursion
• diaphragm normally moves about 3-4 cm and less in
  COPD and neuromuscular diseases

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Auscultation

• Normal lung sounds
• tracheobronchial or bronchial
• loud, coarse, tubular
• tubulent gas flow
• bronchovesicular
• softer, less coarse
• intermediate airways
• increasing surface lung area
• vesicular
• softest, smooth
• laminar gas flow
• largest surface area

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Auscultation

• Adventitious lung sounds
• crackles or rales
• short, intermittent sounds
• air passing through fluid in the small airways
  air suddenly opening up ateletatic lung units
  decreased
• reduced transmission and intensity of sounds when
  compared to normal sounds in the same area
• e.g., hyperinflated lungs, pleural effusion, obese

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Auscultation

• Absent
• no lung sounds noticeable
• e.g., pneumothorax, pneumonia
• Wheezing
• high pitched, continous sound
• heard normally on exhalation
• associated with narrowed airways
• bronchospasm, bronchoconstriction, mucosal edema,
  foreign body obstruction

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Auscultation

• Rhonchi
• low pitched, continuous sound
• associated with excessive secretions in the
  airways which narrows the lumen of large airways
• tends to clear with coughing

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Auscultation

• Stridor
• hoarse sound heard on inspiration
• common post extubation because of tracheal
  swelling and edema causing narrowing of the upper
  airway
• treated with racemic epinephrine, its alpha
  effects reduce mucosal swelling

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Auscultation

• Bronchial
• tubular or tracheal sounds which are transmitted
  from the trachea through consolidation at the
  bases
• sounds transmit better through solid than air
• egophony E to A
• whispered pectoriloquy 99
• bronchophony patients words are heard clear
  through consolidation, but muffled in normal lungs

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Auscultation

• Pleural friction rub
• creaky or grating sounds as the patient breathes
  in and out similar to old leather when it is bent
  to and fro
• related to inflamed or irritated pleural surface
• pleurisy from pneumonia is common