Pulmonary Assessment Flashcards
How do you take heart rate and pulse measurement?
Using the first and second fingertips, press firmly but gently on contralateral radial artery
Count your patient’s pulse for 60 seconds (if taking it a first time or the pt has a known arrhythmia)
Count your patient’s pulse for 15 seconds x 4 if your patient has a known regular rhythm
What are you monitoring when measuring HR and pulse?
Monitor for rate, strength, regularity of the pulse
How should you position the patient for blood pressure measurement?
5-minute rest before taking patient’s BP
Sit in a chair, back supported, legs and ankles uncrossed
Arms should be at the level of the heart – prop on an exam table or pillow
Wrap the BP cuff smoothly and snuggly around the upper part of your patient’s arm (verify that the cuff size is appropriate for your patient)
What is the landmark on the arm for the bottom edge of the cuff when measuring BP?
The bottom edge of the cuff should be > 1 inch above the cubital fossa
Where does the stethoscope go when taking BP?
Place the stethoscope firmly over the brachial pulse
How to actually measure BP?
Ask your patient his/her usual BP
Inflate the cuff 20 – 30 mmHg above your pts usual SBP
Slowly release the cuff pressure
Note the mm HG when the first Korotkoff sound is heard
Continue to slowly release the cuff pressure
Note the mm HG when the last last Korotkoff sound is heard
What is the first Korotkoff sound is heard?
this is the systolic BP
What is the second Korotkoff sound is heard?
this is the diastolic BP
What is normal blood pressure?
systolic: less than 120
diastolic: less than 80
What is elevated BP?
systolic: 120-129
diastolic: less than 80
What is high BP - hypertension stage 1?
systolic: 130-139
diastolic: 80-89
What is high BP - hypertension stage 2?
systolic: 140+
diastolic: 90+
What is hypertensive crisis?
systolic: 180+
diastolic: 120+
consult doctor immediately
How to position patient for orthostatic hypotension?
Position patient in supine for 2 minutes
Take BP
Position patient in sitting with feet flat on the floor
Take a BP
Watch for signs of pre-syncope for 2 minutes
Position patient in standing
Take a BP
Watch for signs of pre-syncope for 2 minutes
What are the S/Sx of Pre-Syncope and Syncope?
SBP < 90
SBP drop > 20 mmHg
HR < 60
Ventricular Arrhythmias
Dizziness
Altered Consciousness
Slurred Speech
Diaphoresis
Ringing in ears
Visual Disturbances or Black Spots
Black Outs
Nausea/Vomiting
Weakness
How to measure respiratory rate?
discretely count the number of breaths your patient takes in 30 seconds x2
What is the RR for <1 year?
30-40
What is the RR for 1-2 years?
25-35
What is the RR for 2-5 years?
25-30
What is the RR for 5-12 years?
20-25
What is the RR for >12 years?
12-20
How to measure oxygen saturation?
Use a Pulse Oximeter to measure oxygen saturation
Place one finger in the pulse ox clip = for best results, no nail polish
Wait a couple of seconds to a digital measure of oxygen saturation
Most pulse ox clips measure O2 and HR
How to calculate BMI?
BMI= weight (kilograms)/height (meters)2
What are the 5 vital signs?
HR
Pulse strength
BP
SPO2
RR
What is the purpose of the chest physical exam?
Establish a baseline for patient treatment tolerance
Observations to compare the day-to-day change in patient pulmonary status
Pathology identified in specific lobes of the lung to guide treatment plan and interventions
Provides a pretreatment standard to compare the post treatment assessment in order to determine the effectiveness of the chest physical therapy performed
The assessment may reveal a new or previously undiscovered pulmonary complication = communication with the patient care team
What is the Pre-Physical Exam Check list?
Chart Review or Intake Form Review
Hand Hygiene & Precautions
Stethoscope, BP Cuff, Pulse Ox
What are the Four Components of Chest Physical Exam?
inspection
palpation
percussion
auscultation
Where is the sternal angle?
located just below the suprasternal notch where a ridge can be palpated on the manubrium
synarthrotic joint formed by the articulation of the manubrium and the body of the sternum
Where is the bifurcation of the trachea?
Bifurcation of the trachea into a right and left main stem bronchi occurs at T5 – T7 or rib 3-4
Where is the trachea?
Trachea lies midline, directly above the suprasternal notch
Tension pneumothorax and lung collapse can cause a shift of the structure within the thorax, deviating the trachea from its normal central position
Where is the infrasternal angle?
The infrasternal angle (subcostal angle) is formed in front of thoracic cage by the cartilages of the tenth, ninth, eighth, and seventh ribs, which ascend on either side, where the apex of which the xiphoid process projects
How do we use the accessory muscles?
typically seen in neck of patient with pulmonary disease
when pulmonary condition is severe accessory muscles are used at rest
not involved during normal quiet breathing
play a role during exercise, during inspiratory phase of cough/sneeze, or in a pathologic state (asthma)
What are the accessory muscles of inspiration?
recruited to assist the diaphragm in creating a sub-atmospheric pressure in the lungs
scalenes
sternocleidomastoid
pectoralis
trapezius
external intercostal
What does jugular venous distention indicate ?
discerned - sign of right ventricular failure from pulmonary hypertension
What does peripheral edema indicate?
Pulmonary fluid present due to right sided heart failure
How do you conduct a Peripheral Edema Assessment?
Press firmly with your thumb for at least 2 seconds on each extremity
> Over the dorsum of the foot
> Behind the medial malleolus
> Lower calf above the medial malleolus
Record indention recovery time in seconds
What does a score of 0 indicate for edema?
no clinical edema
What does a score of 1+ indicate for edema?
≤ 2 mm indentation
Slight pitting
Disappears rapidly
What does a score of 2+ indicate for edema?
2-4mm indentation
Somewhat deeper pitting
No readably detectable distortion
Disappears in 10-15 seconds
What does a score of 3+ indicate for edema?
4-6mm indentation
Pit is noticeably deep
May last >1 minute
Dependent extremity looks fuller and swollen
What does a score of 4+ indicate for edema?
6-8mm indentation
Pit is very deep
Lasts as long as 2-5 minutes
Dependent extremity is grossly distorted
What is digital clubbing?
tips of digits become bulbous due to changes in oxygenation
Typical in patients with chronic pulmonary disease
What is cyanosis?
bluish discoloration of the skin that signals hypoxemia
Common Sites: mouth, eyes, and fingernail beds
How do you analyze a breathing pattern?
Patient in Supine
- Examine neck and anterior chest & accessory muscles
2.Is the inspiration pattern normal? Does the abdomen rise, followed by symmetrical expansion of lateral ribs?
- Is expiration passive?
If abdominal muscles contract it means forced expiration = indicative of obstructive airway disease
What causes decreased chest excursion?
Barrel chest or COPD: chronic over-inflation of the lungs
Scapula dysfunction: fixed to thorax
Musculature weakness due to neurological disease
Scars from previous surgery
What is normal vs abnormal chest excursion?
Normal: full inspiration/expiration is 2.5-5.0 cm
Abnormal: <2.5 cm or >5.0 cm, asymmetrical expansion
Any lung or pleural disease may result in a decrease in overall chest expansion
How to look at Symmetry of Chest Expansion?
patient seated or stand with arms at side
Stand behind patient, put your hands on lower hemithorax on either side of axilla and gently bring your thumbs to the midline
Have patient slowly take a deep breath and expire
Watch the symmetry of movement of the hemithorax; feel symmetry of chest expansion
Stand in front and lay your hands over both apices of the lung and anterior chest and assess chest expansion
The Right middle lobe and lingular portion of left upper lobe are beneath _____
5th and 6th rib
The Lower lobes are seen posterior from ____
7th to 10th rib
How do you palpate for chest excursion?
Your hands should lift symmetrically outward when the patient takes a deep breath
Move your hands to several symmetrical locations posteriorly, laterally, and anteriorly
Processes that lead to asymmetric lung expansion, as might occur when anything fills the pleural space (e.g. air or fluid), may then be detected as the hand on the affected side will move outward to a lesser degree
How do you measure chest excursion?
Wrap a tape measure around your patient’s chest at the axilla, 5th rib, and xiphoid process – make sure the tape measure is level all the way around
Make sure the tape measure is snug around your patient – not tight
Ask your patient to fully inhale – record chest circumference
Ask you patient to full exhale – record chest circumference
Document location of chest excursion measurement
Repeat a couple of times for accuracy and consistency
What is Tactile Fremitus?
Normal lung transmits a palpable vibratory sensation to the chest wall
This is referred to as fremitus
Can be detected by placing the ulnar or palmer aspects of both hands firmly against either side of the chest while the patient says the words “Ninety-Nine”
This maneuver is repeated until the entire posterior thorax is covered. The bony aspects of the hands are used as they are particularly sensitive for detecting these vibrations. The vibrations produced over each lung by the voice is called “vocal fremitus”
What causes increases in vocal fremitus?
caused by lung consolidation
Consolidation occurs when the normally air-filled lung parenchyma becomes engorged with fluid or tissue, most commonly in the setting of pneumonia
What causes decreases in vocal fremitus?
caused by pleural effusions, pleural thickening, pneumonthorax - Pleural fluid
Fluid collects in the pleural space, displacing the lung upwards
What is a percussion?
Used in Chest Exam to discern fluid, air, or solid mass in the chest/lungs
Striking a surface which covers normal lung tissue will produce a resonant sound
Striking a surface over a fluid or tissue filled cavity generates a relatively dull sound or deadened tone =
pleural effusion or pneumonia
Striking a surface over an airfilled surface generates a relatively hyperresonant sound =
emphysema, pneumothorax
How do you administer a percussion?
Percussing with your right hand, stand a bit to the left side of the patient’s back
Ask the patient to cross their hands in front of their chest = This will help to pull the scapulae laterally, away from the percussion field
Work down the “alley” that exists between the scapula and vertebral column = avoid percussing over bone
Try to focus on striking the distal inter-phalangeal joint of your left middle finger with the tip of the right middle finger. The impact should be crisp.
The last 2 phalanges of your left middle finger should rest firmly on the patient’s back. Try to keep the remainder of your fingers from touching the patient, or rest only the tips on them if this is otherwise too awkward, in order to minimize any dampening of the percussion notes
How many taps when doing percussions?
2-3 taps in each location
Then move your hand down several inter-spaces and repeat the maneuver
Percussion in 5 or so different locations should cover one hemi-thorax
Percuss from side to side making comparisons
Consolidation (lobar pneumonia) - auscultation findings:
crackles
bronchial breath sounds
bronchophony
egophony
pectoriloguy
tactile femitus increased as consolidation site
percussion = dullness (large consolidation)
mediastinal shift = none
Pleural effusion - auscultation findings:
decreased breath sounds
decreased tactile fremitus
percussion = dullness
mediastinal shift = away from effusion (for large effusions)
Chronic Obstructive Pulmonary Disease (COPD) - auscultation findings:
decreased breath sounds
decreased tactile fremitus
percussion = hyperresonant (especially if large bullae)
mediastinal shift = none
Pneumothorax - auscultation findings:
decreased breath sounds
decreased tactile fremitus
percussion = hyperresonant
mediastinal shift =
small - none
tension - away from pneumothorax
How do you palpate the movement of the diaphragm?
hands placed on a “V” with thumbs at base of xiphoid process
Prior to listening over any one area of the chest, remind yourself which lobe of the lung is heard best in that region:
lower lobes occupy the bottom 3/4 of the posterior fields
right middle lobe heard in right axilla
Lingula: rib 5/6
upper lobes in the anterior chest and at the top 1/4 of the posterior fields
How do you position the stethoscope for auscultations?
Put on your stethoscope so that the earpieces are directed away from you
Adjust the head of the scope so that the diaphragm is engaged
If you’re not sure, scratch lightly on the diaphragm, which should produce a noise
What fields are examined first?
The upper aspect of the posterior fields are examined first
Listen over one spot and then move the stethoscope to the same position on the opposite side and repeat
This again makes use of one lung as a source of comparison for the other
The entire posterior chest can be covered by listening in roughly 4 places on each side
If you hear something abnormal, you’ll need to listen in more places
When listening to auscultations what should you advise the patient to do?
Ask the patient to take slow, deep breaths through their mouth while you are performing your exam
This forces the patient to move greater volumes of air with each breath, increasing the duration, intensity, and thus detectability of any abnormal breath sounds that might be present
Sometimes it’s helpful to have the patient cough a few times prior to beginning auscultation = this clears airway secretions and opens small atalectic areas at the lung bases.
If the patient cannot sit up, how should you perform auscultations?
auscultation can be performed while the patient is lying on their side
get help if the patient is unable to move on their own
In cases where even this cannot be accomplished, a minimal examination can be performed by listening laterally/posteriorly as the patient remains supine
Requesting that the patient exhale forcibly will occasionally help to accentuate abnormal breath sounds (in particular, wheezing) that might not be heard when they are breathing at normal flow rates.
Where do you stand when examining the lingula and right middle lobes?
The lingula and right middle lobes can be examined while you are still standing behind the patient
move the stethoscope laterally just below the axilla
Then, move around to the front and listen to the anterior fields
This is generally done while the patient is still sitting upright. Asking female patients to lie down will allow their breasts to fall away laterally, which may make this part of the examination easier.
What are diminished breath sounds?
Breath sounds that are quiet and barely audible are diminished
What are bronchial sounds?
Loud, hollow echoing sound during the greater portion of the respiratory cycle are bronchial sounds: bronchi and trachea
Normal breath sounds are called what?
vesicular - - lung tissue
Situations of Absence of Breath Sounds:
In chronic severe emphysema, often small tidal volumes with little air movement
Severe asthma attack
Pleural effusion
Pneumothorax
What are adventitious breath sounds?
Crackles
Rhonci
Wheezing
Stridor
Pleural rub
What are crackles?
(rales)
Scratchy sounds associated with fluid in alveoli and airways:
- Pulmonary edema
- pneumonia
phase - usually inspiratory
pitch - high or low
location - throughout lung fields
What are rhonchi?
gurgling
Fluid in large and medium sized airways:
- bronchitis
- pneumonia
phase - expiratory
pitch - low
location - obstruction of larger airway
What is wheezing?
whistling
Loudest on expiration, caused by air forced thru narrowed airways:
- asthma
Expiratory»_space;»Inspiratory
phase - expiratory
pitch - high
location - obstruction of airway
What is stridor?
inspiratory whistling
due to tracheal narrowing
phase - inspiratory
location - trachea
What is a pleural rub?
discontinuous
grating sounds
biphasic
phase - inspiratory and expiratory
location - localized area of chest wall
What conditions have crackles?
ARDS
asthma
bronchiectasis
chronic bronchitis
consolidation
early CHF
ILD
pulmonary edema
What conditions have wheeze?
asthma
CHF
chronic bronchitis
COPD
pulmonary edema
What conditions have rhonci?
large airway obstruction (secretions)
What conditions have stridor?
obstruction in trachea or larynx
medical emergency
What conditions have pleural rub?
pleural effusion
pneumothorax
What do you do post-physical exam?
patient education
POC
goals
