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Cardio pulm exam 2 > Pulmonary Assessment > Flashcards

Pulmonary Assessment Flashcards

1
Q

How do you take heart rate and pulse measurement?

A

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

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2
Q

What are you monitoring when measuring HR and pulse?

A

Monitor for rate, strength, regularity of the pulse

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2
Q

How should you position the patient for blood pressure measurement?

A

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)

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3
Q

What is the landmark on the arm for the bottom edge of the cuff when measuring BP?

A

The bottom edge of the cuff should be > 1 inch above the cubital fossa

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4
Q

Where does the stethoscope go when taking BP?

A

Place the stethoscope firmly over the brachial pulse

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5
Q

How to actually measure BP?

A

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

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6
Q

What is the first Korotkoff sound is heard?

A

this is the systolic BP

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7
Q

What is the second Korotkoff sound is heard?

A

this is the diastolic BP

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8
Q

What is normal blood pressure?

A

systolic: less than 120

diastolic: less than 80

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9
Q

What is elevated BP?

A

systolic: 120-129

diastolic: less than 80

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10
Q

What is high BP - hypertension stage 1?

A

systolic: 130-139

diastolic: 80-89

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11
Q

What is high BP - hypertension stage 2?

A

systolic: 140+

diastolic: 90+

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12
Q

What is hypertensive crisis?

A

systolic: 180+

diastolic: 120+

consult doctor immediately

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13
Q

How to position patient for orthostatic hypotension?

A

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

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14
Q

What are the S/Sx of Pre-Syncope and Syncope?

A

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

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15
Q

How to measure respiratory rate?

A

discretely count the number of breaths your patient takes in 30 seconds x2

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15
Q

What is the RR for <1 year?

A

30-40

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16
Q

What is the RR for 1-2 years?

A

25-35

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17
Q

What is the RR for 2-5 years?

A

25-30

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18
Q

What is the RR for 5-12 years?

A

20-25

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19
Q

What is the RR for >12 years?

A

12-20

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20
Q

How to measure oxygen saturation?

A

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

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21
Q

How to calculate BMI?

A

BMI= weight (kilograms)/height (meters)2

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22
Q

What are the 5 vital signs?

A

HR
Pulse strength
BP
SPO2
RR

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23
Q

What is the purpose of the chest physical exam?

A

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

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24
Q

What is the Pre-Physical Exam Check list?

A

Chart Review or Intake Form Review
Hand Hygiene & Precautions
Stethoscope, BP Cuff, Pulse Ox

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25
Q

What are the Four Components of Chest Physical Exam?

A

inspection
palpation
percussion
auscultation

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26
Q

Where is the sternal angle?

A

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

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27
Q

Where is the bifurcation of the trachea?

A

Bifurcation of the trachea into a right and left main stem bronchi occurs at T5 – T7 or rib 3-4

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28
Q

Where is the trachea?

A

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

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29
Q

Where is the infrasternal angle?

A

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

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30
Q

How do we use the accessory muscles?

A

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)

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31
Q

What are the accessory muscles of inspiration?

A

recruited to assist the diaphragm in creating a sub-atmospheric pressure in the lungs

scalenes
sternocleidomastoid
pectoralis
trapezius
external intercostal

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32
Q

What does jugular venous distention indicate ?

A

discerned - sign of right ventricular failure from pulmonary hypertension

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33
Q

What does peripheral edema indicate?

A

Pulmonary fluid present due to right sided heart failure

34
Q

How do you conduct a Peripheral Edema Assessment?

A

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

35
Q

What does a score of 0 indicate for edema?

A

no clinical edema

36
Q

What does a score of 1+ indicate for edema?

A

≤ 2 mm indentation
Slight pitting
Disappears rapidly

37
Q

What does a score of 2+ indicate for edema?

A

2-4mm indentation
Somewhat deeper pitting
No readably detectable distortion
Disappears in 10-15 seconds

38
Q

What does a score of 3+ indicate for edema?

A

4-6mm indentation
Pit is noticeably deep
May last >1 minute
Dependent extremity looks fuller and swollen

39
Q

What does a score of 4+ indicate for edema?

A

6-8mm indentation
Pit is very deep
Lasts as long as 2-5 minutes
Dependent extremity is grossly distorted

40
Q

What is digital clubbing?

A

tips of digits become bulbous due to changes in oxygenation

Typical in patients with chronic pulmonary disease

41
Q

What is cyanosis?

A

bluish discoloration of the skin that signals hypoxemia

Common Sites: mouth, eyes, and fingernail beds

42
Q

How do you analyze a breathing pattern?

A

Patient in Supine

  1. Examine neck and anterior chest & accessory muscles

2.Is the inspiration pattern normal? Does the abdomen rise, followed by symmetrical expansion of lateral ribs?

  1. Is expiration passive?
    If abdominal muscles contract it means forced expiration = indicative of obstructive airway disease
43
Q

What causes decreased chest excursion?

A

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

44
Q

What is normal vs abnormal chest excursion?

A

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

45
Q

How to look at Symmetry of Chest Expansion?

A

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

46
Q

The Right middle lobe and lingular portion of left upper lobe are beneath _____

A

5th and 6th rib

47
Q

The Lower lobes are seen posterior from ____

A

7th to 10th rib

48
Q

How do you palpate for chest excursion?

A

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

49
Q

How do you measure chest excursion?

A

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

50
Q

What is Tactile Fremitus?

A

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”

51
Q

What causes increases in vocal fremitus?

A

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

52
Q

What causes decreases in vocal fremitus?

A

caused by pleural effusions, pleural thickening, pneumonthorax - Pleural fluid

Fluid collects in the pleural space, displacing the lung upwards

53
Q

What is a percussion?

A

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

54
Q

Striking a surface over a fluid or tissue filled cavity generates a relatively dull sound or deadened tone =

A

pleural effusion or pneumonia

55
Q

Striking a surface over an airfilled surface generates a relatively hyperresonant sound =

A

emphysema, pneumothorax

56
Q

How do you administer a percussion?

A

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

57
Q

How many taps when doing percussions?

A

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

58
Q

Consolidation (lobar pneumonia) - auscultation findings:

A

crackles
bronchial breath sounds
bronchophony
egophony
pectoriloguy

tactile femitus increased as consolidation site

percussion = dullness (large consolidation)

mediastinal shift = none

59
Q

Pleural effusion - auscultation findings:

A

decreased breath sounds

decreased tactile fremitus

percussion = dullness

mediastinal shift = away from effusion (for large effusions)

60
Q

Chronic Obstructive Pulmonary Disease (COPD) - auscultation findings:

A

decreased breath sounds

decreased tactile fremitus

percussion = hyperresonant (especially if large bullae)

mediastinal shift = none

61
Q

Pneumothorax - auscultation findings:

A

decreased breath sounds

decreased tactile fremitus

percussion = hyperresonant

mediastinal shift =
small - none
tension - away from pneumothorax

62
Q

How do you palpate the movement of the diaphragm?

A

hands placed on a “V” with thumbs at base of xiphoid process

63
Q

Prior to listening over any one area of the chest, remind yourself which lobe of the lung is heard best in that region:

A

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

64
Q

How do you position the stethoscope for auscultations?

A

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

65
Q

What fields are examined first?

A

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

66
Q

When listening to auscultations what should you advise the patient to do?

A

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.

67
Q

If the patient cannot sit up, how should you perform auscultations?

A

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.

68
Q

Where do you stand when examining the lingula and right middle lobes?

A

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.

69
Q

What are diminished breath sounds?

A

Breath sounds that are quiet and barely audible are diminished

69
Q

What are bronchial sounds?

A

Loud, hollow echoing sound during the greater portion of the respiratory cycle are bronchial sounds: bronchi and trachea

70
Q

Normal breath sounds are called what?

A

vesicular - - lung tissue

71
Q

Situations of Absence of Breath Sounds:

A

In chronic severe emphysema, often small tidal volumes with little air movement

Severe asthma attack

Pleural effusion

Pneumothorax

72
Q

What are adventitious breath sounds?

A

Crackles
Rhonci
Wheezing
Stridor
Pleural rub

73
Q

What are crackles?

A

(rales)

Scratchy sounds associated with fluid in alveoli and airways:
- Pulmonary edema
- pneumonia

phase - usually inspiratory
pitch - high or low
location - throughout lung fields

74
Q

What are rhonchi?

A

gurgling

Fluid in large and medium sized airways:
- bronchitis
- pneumonia

phase - expiratory
pitch - low
location - obstruction of larger airway

75
Q

What is wheezing?

A

whistling

Loudest on expiration, caused by air forced thru narrowed airways:
- asthma

Expiratory&raquo_space;»Inspiratory

phase - expiratory
pitch - high
location - obstruction of airway

76
Q

What is stridor?

A

inspiratory whistling

due to tracheal narrowing

phase - inspiratory
location - trachea

77
Q

What is a pleural rub?

A

discontinuous
grating sounds
biphasic

phase - inspiratory and expiratory
location - localized area of chest wall

78
Q

What conditions have crackles?

A

ARDS
asthma
bronchiectasis
chronic bronchitis
consolidation
early CHF
ILD
pulmonary edema

79
Q

What conditions have wheeze?

A

asthma
CHF
chronic bronchitis
COPD
pulmonary edema

80
Q

What conditions have rhonci?

A

large airway obstruction (secretions)

81
Q

What conditions have stridor?

A

obstruction in trachea or larynx

medical emergency

82
Q

What conditions have pleural rub?

A

pleural effusion
pneumothorax

83
Q

What do you do post-physical exam?

A

patient education
POC
goals

Cardio pulm exam 2 (8 decks)

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