Chapter 16 Egans Flashcards
Bedside Assessment
Process of interviewing and examining a patient for signs and symptoms of disease, as well as evaluating the effects of treatment
Diagnosis
Process of identifying the nature and cause of illness
Signs
Objective manifestation of illness
Symptoms
Subjective experience of some aspects of an illlness
Interviewing Purposes
1) Establish rapport between the clinician and patient
2) Obtain info essential for making a diagnosis
3) Help monitor changes in the patients symptoms and response to therapy
Intoduction
Social Space: 4-12ft
Personal Space: 2-4ft
Then get level with patient
Factors affecting communication
~Sensory/Emotional factors
~Environmental factors
~ Verbal/nonverbal components of the communication process
~Cultural
Dyspnea (Difficulty in the mechanical of breathing)
Orthopnea-Dyspnea caused by reclining
~CHF
Platypnea-Dyspnea triggered by assuming upright position
Orthodeoxia-O2 desaturation on assuming an upright position
Trepopnea-Dyspnea from patients with unilateral lung disease lies with the affected side in the dependent position
Breathlessness
The unpleasant urge to breathe
~Triggered by acute hypercapnia, acidosis, or hypoxemia
4 major areas for interviewing for dyspnea
1) What activities of daily living trigger dyspnea?
2) How much exertion makes the patient stop to catch their breath with different activities?
3) Does the quality of dyspnea vary by the type of activity?
4) When did it first become a common future of your life?
Effectiveness of cough depends on
1) Ability to take a deep breath
2) Lung elastic recoil
3) Expiratory muscle strength
4) Level of airway resistance
Restrictive lung diseases
CHF, pulmonary fibrosis
Sputum Production
Phlegm-Mucus from lungs not contaminated
Sputum-Expectorated from mouth
Purulent-Sputum containing pus
Fetid-Sputum that’s foul smelling
Hemoptysis-Coughing up blood
Massive hemoptysis- >300ml in 24 hours
Non-massive hemoptysis- pneumonia, TB, lung cancer, pulmonary embolism
Hematemesis
Blood vomited from the gastrointestinal tract that often occurs in patients with gastrointestinal diseases
Chest Pain
Pleuritic-Located laterally or posteriorly
Non-Pleuritic- Center of the chest that may radiate
Angina- Non-pleuritic chest pain brought on by exertions or stress and is associated with coronary artery occlusion
Pedal Edema- Swelling in lower extremities
Pitting edema- When finger pressure is applied and indention stays
Weeping edema- When applied pressure causes a fluid leak
~ Right-sided/left-sided heart failure
Fun Fact
Chronic hypoxemia causes severe pulmonary vasoconstriction and pulmonary hypertension
Chief complaint
Detailed, systematic account of the patient’s major complaints written by a physician after the postadmission interview
Advance Directive
The patient has formalized his or her wishes for resuscitative efforts
Physical Exam
1) Inspection (visually examining)
2) Palpation (touching)
3) Percussion (tapping)
4) Auscultation (listening)
Indicators for appearance
1) Level of consciousness
2) Facial expression
3) Level of anxiety or distress
4) positioning
Cachexia
Weakness and emaciation
Tripod sign
The patient sits upright with elbows on the table that has pulmonary hyperinflation.
~Position gives a mechanical advantage to the accessory breathing muscles of the upper chest and neck
Level of consciousness
~Sensorium- used when evaluating a patient’s cognitive functioning and level of consciousness
Confused
~Slow mental response
Delirious
~ Irritated
Lethargic
~ Sleepy, arouses easy
Obtunded
~ Awakens only with difficulty
~ Responds appropriately when aroused
Stuporous
~ Does not awaken completely
Comatose
~Unconscious
Vital Signs
Body temp, pulse rate, respiratory rate, blood pressure, pulse oximetry
Body Temperature
37 degrees Celsius (98.6 F)
Pulse rate
60-100 beats per minute
> 100bpm = tachycardia
< 60bpm = bradycardia
^~ Difference between both is Pulse Pressure
~Radial artery is the most common site used to palpate the pulse
Pulsus Paradoxus- Significant decrease in pulse strength during spontaneous inspiration that can be quantified with a blood pressure cuff
Pulsus Alternans- Alternating succession between strong and weak pulses
Respiratory rate
12-18 breathe/minute
~ Tachypnea- Rate > 20 breathes
~ Bradypnea- Rate < 10 breathes
Arterial Blood Pressure
~ Force exerted by the heart against the systemic arteries as the blood moves through them
Arterial-Peak force exerted in the major arteries during contraction of the left ventricle
Diastolic-Force in the major arteries remaining after relaxation of ventricles
Hypertension- > 140/90
~Stage 1: 140-159/ 90-99
~stage 2: >160/ >100
~3Rd stage: pre-hypertension 120-139/80-89
Hypotension-
~ Systolic <90
~ Arterial pressure <65
~ Decrease in systolic pressure >40 from baseline
Shock- inadequate delivery of O2 and nutrients to the vital organs relative to their metabolic demand
Postural hypotension- Postural changes in a hypovolemic patient who often produces hypotension
Syncope- Fainting
Jugular Venous Pressure (JVP)
~Estimated by determining how high the jugular vein extends above the level of the sternal angle
Kussmaul sign-When JVP increases during inhalation
Jugular Venous Distension (JVD)
Present when the jugular vein is enlarged and can be seen more than 4cm above the sternal angle
~Chronic hypoxemia who develops right heart failure from hypoxemia-induced pulmonary hypertension
~ Left heart failure, Cardiac tamponade, tension pneumothoraxes
Lymphadenopathy-Enlarged lymph nodes
Barrel chest
Emphysema
Abnormalities of thoracic configuration
Pectus carinatum-Abnormal protrusion of the sternum
Pectus Excavation- Depression of part or entire sternum
Kyphosis- Spine has an abnormal anteroposterior curvature
Scoliosis- Spine has a lateral curve
Kyphoscoliosis- Combination of both kyphosis and scoliosis
Common causes of increased WOB
Airway obstruction, edematous lungs, cardiogenic (stiff chest wall)
Respiratory muscles
Can generate inspiratory pressures of 150cm H2O (112mm Hg)
Tracheal tugging-Downward movement of the thyroid cartilage toward the chest during inspiration in concert with the sternocleidomastoid muscle recruitment
Kussmaul breathing- Rapid/ deep breathing
~Severe metabolic acidosis
Abnormal Breathing Patterns
Cheyne Stokes- When RR and Vt gradually increase in intensity and then gradually decrease to complete apnea
Agonal breathing- Intermittent prolonged breathing
Apnea- No breathing
Apneustic breathing- Prolonged inspiratory pause at full inspiration typically lasting for 2-3 seconds
Asthmatic breathing- Prolonged exhalation with the recruitment of abdominal muscles
Biot respiration- Chaotic breathing pattern characterized by frequent irregularity in both rate and tidal volume that eventually deteriorates to agonal breathing and terminal apnea
Central neurogenic hyperventilation- Persistent hyperventilation
Paradoxical breathing
~ Abdominal- abdominal wall moves inward on inspiration and outward on expiration
~ Chest- Part or all of the chest wall moves in with inhalation ad out with exhalation
Fatigue vs. muscle weakness
~ Inability of contracting muscles to achieve a target pressure
~ Inability to achieve a target pressure in a rested muscle
Respiratory Alternans
When the diaphragm and ribcage muscles alternately power breathing in an attempt to rest each muscle group
Abdominal Paradox
Complete diaphragmatic fatigue, as the diaphragm is drawn upward into the thoracic cavity with each inspiratory effort of the rib cage muscles
Palpation
touching chest wall to evaluate underlying structure and function
Vocal Fremitus- Vibrations created by vocal cords from speech
Tactile Fremitus- Vibrations felt on the chest wall
Subcutaneous Emphysema- Fine air bubbles collecting in subcutaneous tissues produce a crackling sound and sensation when palpated
Percussion
Tapping on a surface to evaluate the underlying structure
~Penetrates depth of 5-7cm
~Pneumothorax or lung consolidation
Lungs
~Consecutively testing comparable areas on both sides of the chest
~Tympanic- easily heard, moderately low pitched, resonate sound
~Hypertympanic- Louder, deeper, more resonant
Resonance
Dull-muffling effects of increased tissue density
Hyper-hyperinflation or gas trapped in the pleural place
Auscultation
~Listening to bodily sounds
1) Bell 2) Diaphragm 3) Tubing 4) Earpieces
Normal breath sounds
Vesicular- Low, Soft, Peripheral lung areas
Bronchovesicular- Moderate, Around the upper part of the sternum, between the scapulae
Tracheal- High, Loud, Over the trachea
Abnormal breath sounds
Adventitious lung sounds- Additional sounds or vibrations produced by air movement through diseased airways
Crackles- (discontinuous) crackling or bubbling sounds
~Coarse-excess airway secretions moving throughout the airway
~Severe pneumonia, bronchitis
~Fine-sudden opening of peripheral airways
~Atelectasis, Fibrosis, pulmonary edema
Wheezes- (continuous) High or low-pitched quasi-musical sound
~Asthma, congestive heart failure
Stridor- (continuous) loud, high-pitched sound associated with upper airway obstruction and often heard without a stethoscope
Gallop Rhythm
A patient with heart disease who has S3 and S4
Clubbing
Painless enlargement of the terminal phalanges of the fingers and toes associated with numerous cardiopulmonary and other diseases
~COPD
Cyanosis
Peripheral- Poor perfusion of the extremities so that tissues extract more O2
Central- Mucosa or the torso are involved and may signal severe lung diseases
~Becomes visible when the amount of unsaturated hemoglobin in capillary blood when exceeds 5-6g/dL
Capillary Refill
Pressing firmly on the patient’s fingernail until the nail bed is blanched, and then releasing the pressure
~ Normal refill time 3 sec or less
~ Poor output when exceeds 5 sec
Types of cough
Acute- Sudden onset, usually severe with a short course
Chronic- Persistent, and troublesome for more than 3 weeks
Paroxysmal- Periodic, prolonged, and forceful episodes
