Module 4 Flashcards
Chest pain assessment
Ask about discomfort or unpleasant feelings ask patient to point to location; describe quality, quantity or severity; the timing of the pain, the setting in which occurs, and exacerbating factors
Health history for respiratory system
Ask about chest pain, shortness of breath, wheezing, cough, blood streaked sputum
Shortness of breath
Ask about the difficulty breathing; the onset of symptoms; with or without exertion and if with how much exertion produces dyspnea; how many steps can the patient climb before having to pause for breath?
Cough
Acute: last less than three weeks
subacute: 3 to 8 weeks
Chronic: more than eight weeks
Is the cough dry?
if it produces sputum how much, what color, Odor, consistency?
Hemoptysis: assess volume as well as other sputum attributes
Examination of posterior chest
1) Sitting position with arms folded across chest
2) Inspection: shape & movement of chest; any deformities or asymmetry; any abnormal retractions or impaired respiratory movement on one or both sides
3) Palpation: Identify tender areas; assess any visible abnormalities; test chest expansion; feel for tactile fremitus; compare symmetric areas of the lungs
4) Percussion: when comparing two areas, use the same percussion technique in both areas; Learn to identify the percussion notes, healthy lung is normally resonant; Percussion one side of the chest and then the other at each level; Determine the extent of diaphragmatic excursion
5) Auscultation: Identify patterns of breath sounds;
Examination of anterior chest
1) examine in the supine position
2) Inspect the shape and movement of the Chestwall; deformities, asymmetry or abnormal retraction
3) Palpation: Identify tender areas, assess abnormalities, assess chest expansion and tactile fremitus
4) Percussion
5) Auscultation
Vesicular breath sounds
Soft and low pitched
Heard over most of both lungs
Heard through inspiration and continue without pause through expiration, fading away during expiration
Bronchovesicular breath sounds
Inspiratory and expiratory sounds are about equal
Often heard in the first and second interspaces anteriorly and between the scapula
Bronchial breath sounds
Louder, harsher and higher in pitch
Short silence between inspiratory and expiratory
With expiratory sound lasting longer than inspiratory
Heard over the manubrium (the larger proximal airways)
Tracheal breath sounds
Very loud and harsh with a relatively high pitch
Inspiratory and expiratory sounds are about equal
Heard over the trachea and the neck
Crackles (or Rales)
Discontinuous
Intermittent, nonmusical, and brief
Like dots in time
Fine crackles are soft, high-pitched, very brief (5-10 msec)
Course crackles are somewhat louder, lower in pitch, and brief (20-30 msec)
Wheezes and rhonchi
Continuous
> 250 msec, musical, prolonged
Like dashes in time
Wheezes are relatively high-pitched with hissing or shrill quality
Rhonchi are relatively low pitched with snoring quality
Funnel chest
Depression the lower portion of the sternum
compression of the heart and great vessels may cause murmurs
Barrel chest
Increased anterioposterior diameter
normal during infancy, often accompanies aging and chronic obstructive pulmonary disease
Pigeon chest
Sternum is displaced anteriorly, increasing the anteroposterior diameter
costal cartilages adjacent to the protruding sternum are depressed
Traumatic flail chest
Multiple rib fractures may result in paradoxical movements of the thorax
On inspiration the injured area caves inward on expiration it moves outward
Thoracic kyphoscoliosis
Abnormal spinal curvatures and vertebral rotation deform the chest
Distortion of underlying lungs may make interpretation of lung findings very difficult
Tripod position
Patient leans forward and rest the hands on the knees in order to open up airways to make breathing easier usually found in chronic lung diseases like COPD and emphysema
Bronchophony
Spoken words are louder
Epiphany
“ee” heard as “ay”
Whispered pectoriloquy
Whispered words louder and clearer
Stridor
Wheeze that is entirely or predominantly inspiratory
Indicates a partial obstruction of the larynx or trachea and demands immediate attention
Pleural rub
Inflamed and roughened pleural surfaces grate against each other
Produce creaking sounds usually during expiration
Mediastinal crunch
Series of precordial crackles synchronous with the heartbeat not with respiration
Tactile fremitus
Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking
Decreased: pleural effusion, pneumothorax, COPD, asthma, high pitched, very soft
Increased: Consolidation, Towards the top of a large effusion
Atelectasis (Lobar obstruction)
When a plug in the mainstem bronchus (mucous, foreign object) obstructs airflow
Percussion: dull
Trachea may be shifted toward involved side
Breath sounds usually absent when the bronchial plug persists
Emphysema
A type of COPD - Progressive disorder in which the distal airspace is enlarged and lungs become hyperinflated often associated with chronic bronchitis
Percussion: Diffusely hyperresonant
Trachea is midline
Breath sounds are decreased to absent
Decreased tactile fremitus
Asthma
Widespread narrowing of the tracheobronchial tree diminishing airflow to a fluctuating degree. During attacks airflow decreases further and lungs hyperinflation.
Percussion: resonant
Trachea: midline
Breath sounds: often obscured by wheezes
Tactile fremitus: decreased
Plural effusion
Fluid accumulation in the pleural space
Percussion: dull to flat
Trachea: shifted toward opposite side in large effusion
Breath sounds: decreased to absent;$ possible pleural rub
Tactile fremitus: decreased - absent; may be increased toward the top of large effusion
Heart failure
Increased pressure in the pulmonary veins causes congestion and interstitial edema
Percussion: resonant
Trachea: midline
Breath sounds: normal (vesicular); late inspiratory crackles in the dependent portions of the lungs; possible wheezes
Tactile fremitus: normal
Pneumothorax
Air leaks into the plural space, usually unilaterally, lung recoils from the chest wall
Percussion: hyperresonant Or tympanic
Trachea: shifted toward opposite side if much air
Breast sounds: decreased - absent over the plural air; Possible pleural rub
Tactile fremitus: decreased to absent
Cardiac health history
Any chest pain, palpitations, shortness of breath (dyspnea, orthopnea, paroxysmal nocturnal dyspnea) swelling or edema.
Basic cardiac exam
Blood pressure and heart rate
Chest wall anatomy
Jugular venous pulse, carotid upstroke, presence or absence of carotid bruits
Identify and describe point of maximal impulse
Correctly identify S1 and S2 at the base and Apex
Evaluate murmurs
Evaluate pulsus paradoxus
S1 & S2
Closure of the mitral valve produces the first heart sound S1
Aortic valve closure produces the second heart sound S2
Bruit
A murmur like sound arising from turbulent arterial bloodflow
Usually caused by atherosclerotic narrowing of the internal carotid artery
Heave / lift
Noted with palpation
Lifts and heaves are sustained impulses usually produced by an enlarged right or left ventricle or atrium; occasionally by ventricular aneurysm
