FINAL PRACTICAL Flashcards
patient examination
Look at your patient:
- comfortable? facial expression?
- posture, shape of chest?
- extremities: hairy? scars?
- fingers: clubbing?
Vital signs
Breath/lung, heart, voice sounds
Vital sounds
“signs of life”
measures taken to assess the most basic body functions
1: Heart rate
2: Respiratory rate
3: Blood pressure
4: Temperature
5: Pain
6: Gait speed
normal resting heart rate
60-100 bpm
bradycardia
resting <60 bpm
tachycardia
resting >100 bpm
HR locations
Carotid Brachial Radial Femoral Popliteal Tibial Dorsal Pedis
HR response to exercise
normal: HR increases proportionally to workload (~10 bpm per MET (unless on beta blocker))
HR returns to baseline following 2 minutes of rest
abnormal HR response to exercise
flat/blunted: little/no increase
Bradycardic: >10 bpm drop (severe CAD)
Tachycardic: excess rise (deconditioned, dehydrated, decreased SV)
sudden change >20-40 bpm for >3 minutes at rest, during activity, or following a change in position (refer to MD)
factors affecting HR
aging anemia autonomic dysfunction caffeine cardiac muscle dysfunction drugs fear fever hyperthyroidism infection pain sleep disturbances emotions
pulse rhythm
Regular
Irregular
- regularly irregular (usually AFIB-pre beat or skips a beat)
- irregularly irregular (can only take an average for HR)
pulse strength
- indication of circulating blood volume and strength of LV ejection
- increases slightly with inspiration and decreases with expiration
- Paradoxic= amplitude fades with inspiration and strengthens with expiration (notify MD- occurs with COPD)
pulse strength grades
0= absent 1=weak 2=normal 3= full 4= aneurismal/bounding
tips for taking HR
- check in 2 places in older adults and those with DM (pulse diminishes with age- esp distally)
- if diminished or absent, listen for bruit (indicates narrowing)
RPE
rate of perceived exertion, measures total feeling of exertion and fatigue
alternative tool to measure exercise intensity. useful for patients whose HR is affected with meds
inspiratory muscles
diaphragm
external intercostals
interchondrial intercostals
accessory: scales/SCM
expiratory muscles
abdominals
internal intercostals
lung compliance
- related to elasticity of tissues. measured by pressure-volume curve
- decreases: lungs become stiffer and more difficult to expand.
- increases: lungs become easier to distend and more compliant
chest wall compliance and lung compliance can change lung volumes
ventilation
=movement of oxygen in and out of lungs
factors affecting ventilation
chest wall mechanics:
- kyphosis
- scoliosis
- posture
- hyperinflation
- arthritis
pulmonary mechanics:
- airway inflammation, constriction, degeneration
- increased dead space (scar tissue, emphysema)
- ventilation/perfusion
gas exchange mechanics
- pulmonary HTN
- pulmonary edema
- CHF
normal respiration rate
12-20 bpm
increase in rate and depth proportional to workload
max RR achievable with exercise ~50 bpm
respiration rate precaution
> 35 with exercise
respiration rate contraindication
> 45 to exercise
assessing RR
can use talk test and/or dyspnea index
minute ventilation= RR x TV
factors affecting RR
changes in lung compliance
airway resistance
body position
changes in lung volumes and/or lung capacity
tips for taking RR
- take right after HR while still holding wrist
- if unlabored and regular, take for 30s X 2
Observe:
- rate, excursion, effort and pattern
- accessory ms.
- breathing: silent/noisy
- puffed cheeks, pursed lips, nasal flaring, asymmetrical chest expansion
chest breather
?
diaphragmatic breather
- SOB
- helps to be more conscious of breathing
pulse oximetry
=measures arterial oxygen saturation (SaO2) and pulse simultaneously
normal= >95%
don’t exercise: <85%
false pulse oximetry
nail polish acrylic nails chemotherapy anemia cold skin
normal systolic BP with exercise
=7-10 mmHg/MET
abnormal SBP with exercise
HYPOTENSIVE: decreases 10-20mmHg with increased workload
FLAT/BLUNTED: little/no increase
HYPERTENSIVE: excess increase
(should never increase >225 mmHG)
normal diastolic BP with exercise
=little/no change with aerobic exercise
no more +/- 10 mmHg
abnormal DBP with exercise
HYPOTENSIVE: decrease >10 mmHg below resting
HYPERTENSIVE: increase 15-20 mmHg
should not exceed 120 mmHg
pulse pressure
=SBP - DBP
normal= >20
increases with age and with exercise
low PP indicates low CO in adults with acute heart failure.
increased PP indicates vascular wall stiffness and predicts heart failure in HTN patients
factors affecting BP
age blood vessel size blood viscosity force of heart contraction meds diet distended bladder time of recent meal caffeine nicotine alcohol anxiety pain high altitudes
yellow flags for BP
- DBP 75 y/o
- persistent rise/drop in BP over 2 weeks
- steady fall over several years >75 y/o
- lower SBP (65 w/ fall hx
- PP difference >40
- difference >10 from side to side
- BP changes w/ other signs (dizzy, nausea, extreme sweating
- sudden drop in SBP (>10-15) or DBP (>10) with 10-20% rise in HR- ORTHOSTATIC HYPOTENSION
normal temperature
98.7 F
37 C
fever= >100.4
temp can vary by:
- age
- person
- time of day
- where taken on body
elevated temps caused by:
being active being in high temps eating feeling strong emotions menstruating certain meds teething heavy clothing
gait speed
walking speed has been related to dependence, hospitalization, rehab needs, discharge location, mortality
6 minute walk test
3 minute step test
abdominal exam
inspect
auscultate
percuss
palpate (painful area last)
assess each quadrant:
- check for rebound tenderness
- check for masses
- check for muscle guarding
- check for bounding pulse
BMI
weight (kg) divided by height (m) squared
underweight 30
normal heart sounds
S1
S2
S1 heart sounds
“lub”
mitral and tricuspid valves closing at onset of ventricular systole (muscular contraction phase of cardiac cycle- begins at end of diastole)
S2 heart sounds
“dub”
aortic and pulmonic valves closing at onset of diastole (period of relaxation and filling)
abnormal heart sounds
S3
S4
S3 heart sound
“ventricular gallop”
associated with early rapid passive filling of the ventricles immediately after the MV and TV open.
most frequently associated with heart failure but may occur in children and young adults up to age 40.
abnormal in older adults; noncompliant LV, maybe associated with CHF
S4 heart sound
“atrial gallop”
pathological sound of vibration of ventricular filling
associated with HTN, stenosis, hypertensive heart disease or MI
“atrial kick” indicates elevated atrial pressure
murmurs
due to turbulent blood flow; usually heard as a “whooshing” sound
can be normal or pathological
3 categories of murmurs
1: caused by high rates of flow through normal or abnormal valves
2: caused by forward flow through a stenotic or deformed valve
3: caused by backward flow though a valve (regurgitation)
examine the chest
observe body type overall posture chest type look for symmetry coloration scars abnormal movements muscle contraction
rib flares
trying to expand lung
Schamroth’s sign
indicates clubbing
schamroth’s window
intercostal indrawing
because breathing is so tough
intercostal spaces are drawn inwards on inspiration- especially with inspiratory effort
seen in patients with severe obstructive disease
sign of respiratory problems
“BAD CAT”
Breathing that is audible
Active accessory muscles
Dyspnea
Cyanosis/ clubbing
Anterior/posterior diameter >1
Tracheal deviation from midline
eupnea
normal respiratory rhythm
normal: expiration twice as long as inspiration
dyspnea
labored or difficult breathing (usually associated with lung or heart disease and resulting in SOB
hyperpnea
breathing that is regulated to meet an increase demand by the body for oxygen
apnea
temporary cessation of breathing at the end of normal expiration
apneusis
sustained, gasping inspiration followed by short, inefficient expiration which can continue to the point of asphyxia
associated with lesions in the respiratory center in the brain
cessation of breathing in the inspiratory phase
respiratory arrest
failure to resume breathing following a period of apnea or apneusis
cheyne strokes respiration
periodic type of abnormal breathing often seen in terminally ill or brain damaged patients.
biot’s breathing
characterized by repeated sequences of deep gasps and apnea
assessing depth and symmetry of movement
seated
normal findings: 3-5 cm expansion
positive findings:
- <3 cm movement
- unilateral delay suggests atelectasis, pneumonia, and post op guarding
measuring thoracic excursion
standing, T5 and T10
instruct pt to take full inspiration and hold; fully exhales and holds
normal:
- upper chest 3.6 cm (+/- 0.6)
- lower chest 4.9 cm (+/- 0.6)
positive findings: <1.7 cm
breath sounds
generated by the vibration and turbulence of air flowing in and out of the airways and lung tissue during inhalation and exhalation
4 normal breath sounds
1: tracheal
2: bronchial
3: vesicular
4: bronchovesicular
tracheal breath sounds
high pitched and loud heard over trachea alone
~wind blowing through a pipe
bronchial breath sounds
heard adjacent to the sternum and over major airways
similar to tracheal sounds but not as loud
louder on expiration than inspiration
when heard in other areas, are abnormal
-may be due to consolidated, compressed or airless tissue
vesicular breath sounds
- low pitched and muffled
- inspiration is louder, longer and higher pitched than expiration (very brief)
- normal in all areas of lung except over trachea
bronchovesicular breath sounds
inspiration/expiration are similar lengths at the same pitch with a slight break between the two
normal when heard adjacent to sternum at costo-sternal border or between scapulae at T3-T6
normal lung sounds
have pt do at least 1 full breath when listening to each area
4 spots anteriorly
14 posteriorly
5 abnormal lung sounds
1: bronchial
2: vesicular
3: fine crackles
4: wheezing/Rhonchi
5: coarse crackle
abnormal bronchial lung sounds
when heard at a distance from large airways, it is considered abnormal
most likely indicated a consolidated lung
vesicular lung sounds
- sound heard over the chest at a distance from large airways
- “soft” soft that has been compared to the sound of wind blowing through the leaves of a tree
- longer inspiration than expiration
- most common sound heard in the absence of lung disease
fine crackle lung sounds
“discontinuous” intermittent, “explosive” sounds
high pitched, popping sound of airways opening
heard in atelectasis, interstitial pulmonary fibrosis and sometimes in healthy people
wheezing/ rhonchi
continuous high, medium or low pitched whistling sounds
caused by airway narrowing (bronchospasms), secretions
heard on either inspiration or expiration or both
expiratory more common- associated with diffuse airway obstruction- CF, chronic bronchitis, asthma
coarse crackle lung sounds
intermittent “bubbling” sound
caused by secretions in airways
not as high pitched as fine crackles
voice sounds
used in examination of the chest to determine the presence/absence of consolidation (pneumonia, cancer, hemothorax, something dense filling the airspace)
1: egophony
2: bronchophony
3: whispered pectoriloquy
4: fremitus
egophony
- listen to chest with stethoscope all along different lobes
- patient says the letter “E”
normal: sounds like muffled long E sound
presence of consolidation (pneumonia, cancer) will hear a higher pitched sound like “A”
“E to A changes”
bronchophony
- listen to stethoscope to symmetrical areas of the patient’s lungs
- asks patients to repeat a work (99, 66)
normal: sound becomes less distinct (quieter) as move to periphery of lungs; muffled, indistinct sounds
presence of consolidation: voice remains loud or becomes louder in periphery; 99 sounds normal
may be noted as “increased breath sounds”
whispered pectoriloquy
refers to the loudness of a whispered voice while listening to the lungs with a stethoscope
-ask pt to whisper “1,2,3” repeatedly
normal: whispered sounds would be faint or not heard
presence of consolidation: they are heard
voice fremitus
- vocal or tactile fremitus is the vibration produced by the voice and transmitted to the chest wall
- PT evaluated fremitus by comparing the intensity of the vibrations detected by each hand during quiet breathing and speech
normal: equal and moderate vibrations are noticed during speech
increased: indicates a loss or decrease in ventilation in the underlying lung
decreased: indicates increased air within the lung bc sound is similarly transmitted more poorly through a hyper-inflated lung
tactile fremitus
pt seated
-place ulnar hand over posterior thorax between SP and scapula
pt repeats “99” and PT notes bilateral differences
repeat on anterior chest at supraclavicular area, lateral to sternum below T4
percussion
?
6 MWT
submax tests
better reflects function activities/ADLs
used to assess: pts who have heart and lung disease, functional status, and predictor of mortality and morbidity
does not replace cardiopulm exercise testing, stress testing or VO2 max testing (complementary test)
patient preparation
- comfortable clothing should be worn
- appropriate shoes for walking should be worn
- patients should use usual walking aids
- pt’s medical regimen should be continued
- a light meal is acceptable before
- pts should not have exercised vigorously w/in 2 hours before test
- *pt should sit at rest in a chair, located near the start, for at least 10 min before the test starts. during this time, check for contraindications, measure pulse and BP, and make sure that clothing and shoes are appropriate.
- pulse oximetry
- Borg scale
- pt rate their baseline dyspnea and overall fatigue using the Borg scale
object of the 6 MWT
to walk as far as possible for 6 minutes. you will probably get out of breath or become exhausted. you are permitted to slow down, stop and rest as necessary.
*to walk AS FAR AS POSSIBLE for 6 min, but don’t run or jog
3 step protocol
step height= 16.25”
step for 3 minutes
females: 22 complete step ups per min (88bpm metronome)
males: 24 complete step ups per min (96 bpm metronome)
take pulse for 30s immediately after test and multiple by 2
can’t clear airway, susceptible to:
- obstruction (due to heavy secretions)
- inflammation
- infection
- atelectasis
- abnormal ventilation/perfusion relationships
- deterioration of arterial blood gas values
