Introducing Practice Flashcards by Evie Gilmour

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

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What does a pale skin colour suggest?

Anaemia

Low BP

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What does a Ruddy (red cheeks) skin colour suggest?

Retaining CO2

Increased RBC

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What does a cyanosed(blue) skin colour suggest?

Lack of oxygen
Central
Peripheral

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What are the signs there is a problem?

Shortness of breath 
Sputum 
Cough 
Wheeze 
Pain 
Changes in exercise tolerance 
Functional ability 
Psychosocial changes

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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

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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

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What do you look for in their eyes during observation?

Pallor - anaemia 
Plethora - high Hb
Jaundice - liver/blood 
Drooping 
Oedema - fluid retention

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What do you look for in their hands during observation?

Flapping tremor 
Fine tremor 
Wastage 
Clubbing 
Nicotine stains 
Cyanosis 
Temperature - hot&cold

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What causes clubbing?

Cardiac
- congenital heart diseases 
- bacterial endocarditis 
Lung disease 
- infective (bronchiectasis, lung abscess, emphysema)
- fibrotic 
-malignant

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What do you look for in the mouth during observation?

Dry/dehydrated
Hydrated
Cyanosis
Pursed lip breathing

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What do you look for in oedema during observation?

Peripheral

Pitting

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What do you look for in their position during observation?

In bed slumped?, in a chair?
Position of ease
Fixing

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What do you look for in their chest shape?

Scoliosis 
Kyphosis 
Kyphoscoliosis 
Pectus excavatum (funnel chest)
Pectus carinatum (pigeon chest)
Hyperinflated/barrel

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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

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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