Lecture 21: Pulmonary Eval and Assessment Flashcards
what happens in chart review
determine important info about pt, medical condition, hx, and indications/contraindications
what happens in subjective interview
determine:
- PLOF
- pt goals
- cognition
- barriers to care
- communication
- social hx
what happens with physical exam
determine:
- vitals
- cardiorespiratory impairments
- activity tolerance
- limitations
- functional capacity
what happens with patient assessment
determine:
- discharge needs
- POC
- frequency of treatment
- interventions
what happens with prognosis/outcome
determine prognosis for functional recovery and goal for outcomes
orders give you what sort of info
bedrest orders
specific vital ranges
new O2 needs/changing needs
precautions
device precautions/restrictions
medications in EMR give you what info
scheduled meds
PRN meds
continuous drips
dosage
medical events in EMR give you what info
code/cardiac arrest
sx procedures
device implantation
diagnostics
vital signs in EMR give you what info
current, previous, and TRENDS throughout day
surgery info in EMR gives you what info
changes to POC
new precautions
planned vs elective
ability to be extubated in OR or PACU
length of sx gives you what info
possible impact on cognition
impacts time on mechanical vent post op
DNR/DNI tells you qht
Does pt want to be intubated or resuscitated in event of medical emergency
prior documentation tells. you what
MD notes: consults, op notes, DC summaries, etc
PT/OT/ST notes
CM notes: PLOF, previous living situation, baseline activity, etc
Intake and output gives you what kind of info
info about hydration, kidney function, meds, etc
fluid restrictions
nursing mobility gives you what info
OOB to chair
bathroom
ambulation
changes in bed position, turning schedule
premorbid status provides what info
EMS notes
ER notes
H&P
prior PT notes
where did pt reside prior to admission
baseline mobility
insurance coverage gives you what info
qualification for rehab
post acute PT services
O2 needs
pulm rehab
oxygen delivery in EMR gives you what type of info
current, previous, TRENDS during hospital stay
use device for sleep and different one for day?
communication with respiratory therapy on status, options, etc
what types of questions do you want to ask pulmonary patients about their prior level of function
home set up
baseline mobility/ADLs; limited by activity tolerance or pull S&S?
baseline activity tolerance; ask specific questions; SOB or fatigue with activity?
use of AD; how is device used with O2 simultaneously?
use of O2; type/amount/frequency; portable or stationary; compliance
falls? trip over O2 device?
types of pulmonary S&S; can you suggest energy conservation ideas?
what do you want to observe about a pulmonary patients posture
tripoding
kyphosis/scoliosis/rounded shoulders
supine vs sitting
hyperinflation
body habits
what do you want to observe about a pulmonary patients MSK appearance
accessory mm use
mm wasting
cachexia
signs of hypoxemia/hypoxia
cyanosis or grayed appearance
pallor/mottling
AMS
what to observe in regard to breathing patterns with pulmonary patients
rate/rhythm/effort
cough assessment
sounds
at rest vs during conversation vs activity
mouth open vs mouth closed
components of the cough assessment
type/description
strength
effectiveness
duration vs frequency
secretion management
types/descriptions of coughs
productive/wet
- clear discolored secretions can differentiate between pathology and infection
- frothy/foamy secretions indicate pulmonary edema/HF
non-productive/dry
hemoptysis
“barking” or “whooping”
what to look at with strength of cough
does cough become more productive with abdominal splinting
what to look at with cough effectiveness
does coughing change their exam or symptoms
interpretation/dx of productive cough
bacterial PNA
obstructive disease
non-productive cough interpretation/dx
viral PNA
IPF
smoking
purulent cough interpretation
bronchiectasis
chronic bronchitis
fungal PNA
blood tinged cough interpretation
TB
cancer
early fibrosis
blood predominant cough interpretation
alveolar hemorrhage, PE, UGIB
“brassy” cough interpretation
alveolar hemorrhage
PE
UGIB
frothy cough interpretation
HF
pulmonary edema
violent cough interpretation
foreign body aspiration
choking
barking/”whooping” cough interpretation
pertussis
what to palpate with pulmonary pts
mm of ventilation
chest wall mobility
thoracic cavity mechanics
tactile fremitus
- vibration caused by retained secretions or abnormal air movement
- can be made worse with speaking or coughing
- wide variety of presentations
mediate percussion evaluates what
lung density and diaphragmatic excursion
what 3 normal sounds can be produced with mediate percussion
normal = lung tissue and resonance is normal
dull = “thud” or dense resonance felt over area of fluid consolidation or non-aerated tissue
tympanic = loud, hollow resonance felt over area of hyperinflation
technique for mediate percussion
middle finger of non-dominant hand placed flat on chest wall in IC space
middle finger of dominant hand strikes the finger on the chest wall in rapid succession
describe lung auscultation
diaphragm is best for hearing normal sounds
bell is best for hearing abnormal
performed over entire lung space in systemic manner, anteriorly then posterior
at least 1 breath should be auscultated in each bronchopulmonary segment
normal sounds are created by the turbulence in air flow
which lung has the cardiac notch
left
describe bronchial auscultations (normal)
heard over tracheobronchial tree
louder/high pitched than vesicular
louder during exhalation but still heard at the end of inhalation
describe bronchiovesicular auscultations (normal)
heard over mainstem and segmental bronchi OR between shoulder blades
softer versions of bronchial auscultation
heard equally during inhalation and exhalation
describe vesicular auscultation (normal)
heard through all lung fields
soft, lower pitched
louder during inglantoion but still heard at beginning of exhalation
another name for abnormal breath sounds/lung auscultation
aka adventitious lung sounds
possible causes of abnormal breath sounds
increased tissue density increases sound transmission (water carries sound better than air)
consolidative pathology creates stronger/louder sounds (i.e. PNA, tumors)
areas of hyperinflation greater weaker/softer sounds (i.e. emphysema)
areas without air movement create no sound at all (i.e. pneumothorax, obstructive atelectasis)
what is whispered pectoriloquy
whispered words (usually counting) are heard loudly in presence of fluid consolidation
normally would not be heard during auscultation
what is bronchophony
normal volume words/numbers are heard louder than normal in the presence of fluid consolidation
normally would be heard at a normal volume
what is egophony
high pitched “nasal” sound transmitted through areas of fluid consolidation
“EEE” sounds like “AAA”
normally “EEE” sounds like “EEE”
describe a wheeze
continuous musical sound
more common to heard during exhalation from airway obstruction
wheezing with inhalation indicates a more severe obstruction
must differentiate between expiratory wheeze and inspiratory wheeze to differentiate pathology
describe a rhonchi
continuous lower pitch than wheezing
heard during inhalation and exhalation
caused by copious airway secretions
describe stridor
continuous high pitched sound
higher intensity than wheezing
severe upper airway obstruction
can be caused by edema, anaphylactic allergic reaction, tumor burden, bleeding, choking, recent extubation, etc
describe crackles (rales)
discontinuous sound
sounds like brief bursts of popping bubbles, velcro ripping apart, wood burning
most common during inhalation as a result from sudden opening of closed airway
other causes:
- bronchitis
- atelectasis
- pulmonary edema
- fibrosis
describe pleural rub
either continuous or discontinuous
sounds like pieces of leather or sandpaper rubbing together
indications inflammation of pleura
heard best at lower lateral chest wall
usually accompanied by pain
