Introducing Practice Flashcards
What do you look for in the chest breathing pattern?
Depth
Chest movement - all elements together
Indrawing/recession of intercostal space
Paradoxial/Hoovers sign/frail rib fractures
Tracheal tug
Asymmetry
What does a pale skin colour suggest?
Anaemia
Low BP
What does a Ruddy (red cheeks) skin colour suggest?
Retaining CO2
Increased RBC
What does a cyanosed(blue) skin colour suggest?
Lack of oxygen
Central
Peripheral
What are the signs there is a problem?
Shortness of breath Sputum Cough Wheeze Pain Changes in exercise tolerance Functional ability Psychosocial changes
What is in the objective assessment?
Observation Palpation Auscultation Chest x-rays & imaging Pulmonary function tests Pulse oximetry Arterial blood gases Functional ability/quality of life Exercise tolerance/tests Charts
What do you look at in observation?
General appearance Position Chest Skin colour Abdomen Use of accessory muscles Nasal flaring Lines, drains etc Oxygen therapy Quality of voice
What do you look for in their eyes during observation?
Pallor - anaemia Plethora - high Hb Jaundice - liver/blood Drooping Oedema - fluid retention
What do you look for in their hands during observation?
Flapping tremor Fine tremor Wastage Clubbing Nicotine stains Cyanosis Temperature - hot&cold
What causes clubbing?
Cardiac - congenital heart diseases - bacterial endocarditis Lung disease - infective (bronchiectasis, lung abscess, emphysema) - fibrotic -malignant
What do you look for in the mouth during observation?
Dry/dehydrated
Hydrated
Cyanosis
Pursed lip breathing
What do you look for in oedema during observation?
Peripheral
Pitting
What do you look for in their position during observation?
In bed slumped?, in a chair?
Position of ease
Fixing
What do you look for in their chest shape?
Scoliosis Kyphosis Kyphoscoliosis Pectus excavatum (funnel chest) Pectus carinatum (pigeon chest) Hyperinflated/barrel
What do you look for in their chest wall movement?
Symmetrical increase in antero-posterior, transverse & vertical diameters of chest
2 components
-antero-posterior angle/pump handle
-transverse angle/bucket handle
What do you look for in their chest work of breathing & shortness of breath?
WOB & SOB
Links to position, pursed lip breathing & accessory muscle
Able to talk in full sentences?
Needing pauses inbetween sentences?
What do you look for in their abdomen?
In a reclined but not slumped posture
Applying a flat hand & palpate gently the abdomen just below the rib cage
Does the abdomen feel soft & mobile? Would the diaphragm be able to descend fully?
What are the accessory muscles of inspiration?
Sternocleidomastoid Latissimus dorsi Scalene Serratus anterior Pectoralis major and minor
What are the accessory muscles of expiration?
Rectus Abdominus External oblique Serratus posterior/inferior Internal oblique Transverse Abdominus Iliocostalis (lower fibres) Quadratus Lumborum
What do you look for in nasal flaring in observation?
Dilation of nostrils
Mainly seen in children
Attempt to decrease airway resistance
Lines, drips and drains
Be aware
Make sure where they’re supposed to be
What to look for with oxygen therapy
Type
Amount
Going up or down
What do you look for in quality of voice?
Loudness
Wet sounding
Talking on full sentences
Audible sounds
What do you palpate?
Abdomen Chest expansion Trachea Sputum crackles/tactile fremitus/vocal fremitus Pain Body temperature Skin Surgical emphysema Scars Response to touch
What do you look for on palpation of abdomen?
Any movement
Any distension
Close relationship with diaphragm
Distended inhibits diaphragmatic movement -> restricts lung volumes & increases WOB
What do you look for on palpation of chest expansion?
Combine observation and palpation
Hands on area of movement
What do look for on palpation of trachea?
Where is it in relation to sternal notch?
Deviation?
Tactile fremitus, vocal fremitus
Tactile fremitus is the transmission of crackles felt on the outside of the chest wall
Vocal fremitus measures speech vibrations transmitted through the chest wall. It increases when the underlying lung tissue is solid (consolidation) in some way & decreases in patients with pneumothorax or effusions
What do you look for on palpation of skin & body temperature?
Cold Clammy Hot Sweaty Hydration
What do you look for on palpation in relation to surgical emphysema?
Air in the subcutaneous tissue of the chest, neck or face
Characteristic crackling on touch
Sign of pneumothorax
What do you look for in scars & response to touch on palpation?
Note previous scars - cardiac & thoracic surgery, injury
Does the pattern of breathing alter on palpation
What are other methods used in an objective?
Auscultation Chest x-rays Pulse oximetry Pulmonary function tests Functional ability Quality of life Arterial blood gases Charts Exercise tests
Functional ability/quality of life
Mixture of questionnaires
Occupation
Social history
In-hospital independence
What are the exercise tolerance tests
6 min walk test Incremental shuttle walk test 3 min shuttle walk test Endurance shuttle test Chair-stand test Stair climbing test
What are the different types of charts?
Blood pressure Heart rate Temperature Oxygen requirements Oxygen saturations Respiratory rate Weight AVPU - level of consciousness Fluid balance Urine output Medications
Critical care charts
Mode of ventilation FiO2 Heart rhythm Pressure support/volume control Airway pressure Tidal volume PEEP CVP GCs/AVPU ABGs Blood chemistry
What is ventilation perfusion matching?
Ventilation and perfusion need to be in the same place at the same time for gas exchange to occur
The VQ ratio quantifies this match
Perfect match 1:1 and for normal blood gases achieved with a ratio of 0.8:1
What is V/Q ratio?
V & Q increase independently from top to bottom of the lung that occurs in the vertical plane regardless of body position
Q is increase to a greater extent because gravity exerts a greater effect on blood than inspired air
