Pulmonary Exam & Assessment

Question 1

during a chart review, what are you looking for under:
- orders

Answer 1

new O2 needs, changing O2 needs
look at O2 goals

Question 2

during a chart review, what are you looking for under:
- teams involved in care

Answer 2

primary vs consulted
is pulmonology consulted? do they need to be?

Question 3

during a chart review, what are you looking for under:
- vital signs and labs

Answer 3

trends during hospital stay

Question 4

during a chart review, what are you looking for under:
- imaging

Answer 4

urgent/emergent vs. routine imaging
** be aware of imaging ordered “stat”

Question 5

during a chart review, what are you looking for under:
- surgeries

Answer 5

how long were they requiring mech. ventilator –> their pulmonary status may not support high intensity exercise right away

Question 6

during a chart review, what are you looking for under:
- nursing mobility

Answer 6

OOB to chair/bathroom?
any ambulation
changes in bed position, turning schedule

Question 7

during a chart review, what are you looking for under:
- insurance coverage

Answer 7

qualification for rehab placement, post acute PT services
O2 needs –> pulmonary rehab

Question 8

during a chart review, what are you looking for under:
- oxygen delivery

Answer 8

do they use certain devices for sleep and different device when awake?
communication with respiratory therapy on status, options, etc.

Question 9

what do you want to know about the patient’s prior level of function?
– _____ set up
– baseline functional mobility/ADLs
– baseline activity tolerance
– use of assistive device
– use of O2
– Falls
– types of pulmonary symptoms

Answer 9

– home
– limited by activity tolerance/pulmonary symptoms, something else?
– tasks they can complete, shortness of breath vs. fatigue with activities
– specific situations requiring AD, how is device used with O2 simultaneously
– type, amount, frequency. portable O2 or stationary concentrator. are they compliant?
– tripping over O2 devices?
– can we make suggestions on energy conservation/activity pacing?

Question 10

portable oxygen =
stationary concentrator =

Answer 10

– bring with you. like a bag or portable tank. doesn’t last long. patients that only need a little bit of O2
– device that stays at home with a long cord –> be careful of tripping over the cord

Question 11

what are things to observe about a patient’s posture?

Answer 11

tripoding –> anchoring of UE to help breathing mechanics
kyphosis/scoliosis/rounded shoulders
supine vs. sitting
hyperinflation signs (ex. clavicles near ears)
body habitus

Question 12

what are things to observe about a patient’s musculoskeletal appearance?

Answer 12

accessory muscle use
muscle wasting
cachexia (weight loss)

Question 13

what are signs of hypoxemia/hypoxia to be aware of in your patients?

Answer 13

cyanosis or grayed appearance
pallor, mottling
AMS
tachycardia
dyspnea

Question 14

what should you observe about your patient’s breathing patterns?

Answer 14

rate, rhythm, effort
cough assessment
sounds
at rest vs. during conversation vs during activity
mouth open vs mouth closed

Question 15

what are different types of coughs?

Answer 15

– productive/wet –> clear/discolored secretions can differentiate between pathology or infection
– non-productive/dry
– hemoptysis
– barking or whooping

Question 16

frothy/foamy secretions indicate:

Answer 16

pulmonary edema
HF

Question 17

what are we looking for during a cough assessment?

Answer 17

• strength –> more productive with abdominal splinting?
• effectiveness –> does coughing change symptoms?
• duration vs. frequency
• secretion management –> risk for aspiration

Question 18

what is the interpretation/diagnosis of cough types:
– productive
– non productive

Answer 18

– bacterial PNA, obstructive disease
– viral PNA, IPF, smoking

Question 19

what is the interpretation/diagnosis of cough types:
– purulent
– blood-tinged
– blood-predominant

Answer 19

– bronchiectasis, chronic bronchitis, fungal PNA
– TB, cancer, early fibrosis
– alveolar hemorrhage, PE, UGIB

Question 20

what is the interpretation/diagnosis of cough types:
– brassy
– frothy
– violent
– barking/whooping

Answer 20

– aortic aneurysm
– HF, pulmonary edema
– foreign body aspiration, choking
– pertussis (whooping cough)

Question 21

what structures do we want to palpate in our pulmonary patients?

Answer 21

muscles of ventilation
chest wall mobility
thoracic cavity mechanics
tactile fremitus

Question 22

what does mediate percussion evaluate?

Answer 22

lung density and diaphragmatic excursion

Question 23

what 3 types of sounds can be produced with mediate percussion?

Answer 23

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

Question 24

what is the technique used to perform mediate percussion?

Answer 24

middle finger of non-dominant hand placed flat on the chest wall in the IC space
middle finger of dominant hand strikes the finger on the chest wall in rapid succession

Question 25

_____ on stethoscope is best for hearing normal sounds
_____ on stethoscope is best for hearing abnormal sounds

Answer 25

diaphragm
bell

Question 26

when performing lung auscultations, it is performed over ____

Answer 26

entire lung space in systematic manner, anteriorly then posteriorly

Question 27

during lung auscultation, at least on breath should be auscultated in _______

Answer 27

each bronchopulmonary segment

Question 28

how are normal sounds created in the airways?

Answer 28

by the turbulence of airflow in airways

Question 29

what patient position is easiest to hear lung sounds?

Answer 29

sitting

Question 30

** slide 22 ** respiratory auscultation pattern, anterior and posterior
– what is one benefit of this pattern?

Answer 30

compares similar segments from one another by switching back and forth between R and L sides

Question 31

true or false. there is ONE correct way to perform lung auscultations.

Answer 31

false - no right or wrong way - just make sure you’re consistent
– you need to be able to compare anatomically sounds from R vs. L

Question 32

Normal Breath sounds:
bronchial:
– heard over _____
– __(louder/softer)__, __(higher/lower)___ pitched than vesicular
– __(louder/softer)___ during exhalation, but still heard at _____ of inhalation

Answer 32

– tracheobronchial tree
– louder, higher
– louder ; end

Question 33

normal breath sounds:
bronchiovesicular:
– heard over ____
– __(louder/softer)___ version of bronchial
– heard _____ during inhalation and exhalation

Answer 33

– mainstem and segmental bronchi OR between shoulder blades
– softer
– equally

Question 34

normal breath sounds:
vesicular:
– heard through _____
– __(loud/soft)___, __(higher/lower)___ pitched
– ___(louder/softer)___ during inhalation, but still heard at _______ of exhalation

Answer 34

– all lung fields
– soft, lower
– louder ; beginning

Question 35

abnormal breath sounds aka adventitious lung sounds:
– increased tissue density _____ sound transmission

Answer 35

increases
– water carries sound better than air

Question 36

abnormal breath sounds:
identify and give example of pathology for each:
– consolidative pathology creates _______ sounds
– areas of hyperinflation create ______ sounds
– areas without air movement at all create _____ sound

Answer 36

– stronger/louder –> pneumonia, tumors
– weaker/softer –> emphysema
– no –> pneumothorax, obstructive atelectasis

Question 37

abnormal breath sounds while auscultating:
whispered pectoriloquy:
– whispered words (usually counting) are heard _____ in the presence of fluid consolidation
– what is normal?

Answer 37

– loudly
– wouldn’t be heard at all

Question 38

abnormal breath sounds while auscultating:
bronchophony:
– normal volume words/numbers are heard _____ in the presence of fluid consolidation
– what is normal?

Answer 38

– louder than normal
– would be heard at normal volume

Question 39

abnormal breath sounds while auscultating:
egophony:
– high-pitched, _____ sounds transmitted through areas of fluid consolidation
– EEE sounds like _____
– what is normal?

Answer 39

– nasal
– AAA
– EEE sounds like EEE

Question 40

abnormal breath sounds can be categorized into ____ or _____ sounds

Answer 40

continuous or discontinuous

Question 41

abnormal breath sounds:
wheezes:
– ______ sound
– more common to hear during _____ from ____
– wheezing with ______ indicates a more severe airway obstruction
– must differentiate between ___ and _____ wheeze to differentiate pathology
– example:

Answer 41

– continuous, musical
– exhalation from airway obstruction
– inhalation
– expiratory or inspiratory
– asthma

Question 42

abnormal breath sounds:
rhonchi:
– _____ sound
– heard during ___
– caused by ____

Answer 42

– continuous, lower pitch than wheezing
– inhalation and exhalation
– copious airway secretions

Question 43

abnormal breath sounds:
stridor:
– ____ sound
– ____ intensity than wheezing
– ____ upper airway obstruction
– can be caused by:

Answer 43

– continuous, high-pitched
– higher
– severe –> medical emergency!
– edema, anaphylactic allergic reaction, tumor burden, bleeding, choking, recent extubation

Question 44

abnormal breath sounds:
crackles (Rales):
– ______ sound
– sounds like:
– most common during _____ as a result from sudden opening of closed airways
– causes:

Answer 44

– discontinuous
– brief bursts of popping bubbles, velcro ripping apart, wood burning
– inhalation
– bronchitis, atelectasis, pulmonary edema, fibrosis

Question 45

abnormal breath sounds:
pleural rub:
– ______ sound
– sounds like:
– indicates:
– heard best at _____
– usually accompanied by ____

Answer 45

– continuous or discontinuous
– pieces of leather or sandpaper rubbing together
– inflammation of pleura
– lower lateral chest wall
– pain

Question 46

what is the PT role with breath sounds?

Answer 46

we are not diagnosing!
However, knowledge of different breath sounds can guide our interventions to assist in improving abnormal breath sounds

Question 47

how can we bridge the gap between baseline and current baseline?

Answer 47

activity pacing, energy conservation, compensatory strategies, AD use