Pulmonary Examination Flashcards
Chest Wall Excursion Skills
-Direct Technique
-Tape Measure
Chest Wall Examination SKills
-Bronchohony
-Egophony
-Whispered Pectoriloquy
-Mediate Percussion
-Diaphragmic Excursion
Trachial Deviation
-determine if trachea is in midline position
Lower Lateral Costal Breathing
Explain: I’m going to show you how to focus on your ribs movements as you breathe to make sure you get enough air in, i will be palcing my hand on the sides of your lower ribs
-position Pt < palpate lower ribs < instruc Pt to “breathe into my hands”
Abnormal Breathing
- inward motion of abdomen during inhalation
-upper chest moves excessively
-excessive use of accessory muscles
Diaphragmatic Breathing
-ease breathing in a controlled manner
-in all positions
Explain: I’m going to teach you a breathing technique tha focuses on using your diaphragm so you can do less work to breathe
Position patient upright < palpate diaphram and place Pt hand on it and upper chestt < instruct them to breath in through the nose and slowly through their mouth < encourage them to feel it more in their belly than chest
Segmental Breathing
Explain: I’m going to teach hhow to focus on expanding different parts of your belly and chest as you breathe so we can decrease the amount of work your body has to do
-i will be palcing my hand on your chest and belly
-place hand in diaphragm scoop < instruct to breathe into hand < place other hand low on sternum < instruct to breathe into hand < place first hand into upper sternum < instruct to breath into hand
Scoop Diahragmatic Breathing
-allows Pt to feel the breathing in their diaphragm as they do it by following the scoop motion, self cues
-“i will be palcing my hand on the front of your stomach”
-position patient up right < palpate breathing pattern < scoop diaphragm instruct to “breathe into hand” < scoop upward during exhalation < after some breaths place Pts hand there
-CHANGE POSITION IF NEEDED
Sniffing Breathing Technique
-Pt with weak diaphragm or controlled doesn’t work
-sit patient up with bent knees
Intruct:
-3 small sniffs, let it out slowly
-2 small sniffs, let out slowly
-1 long sniff, let out slowly
Pursed Lip Breathing
-used with emphysema Pt
-slows down exhalation and maintains pressure in airways
-makes it easier for next breath
Relax mouth < inhale < purse lips and exhale slowly
DONT USE IF ACUTELY SOB
Basic Ventilatory Strategies for Inhalation
-trunk extension
-shoulder flexion, abduction, ER
-against gravity
Basic Ventilatory Strategies for Exhalation
-trunk flexion
-shoulder extension, adduction, IR
-into gravity
Posture Strategies for Ventilation
-Butterfly technique (w/ rotation)
-Modified PNF Bilateral UE (flx/ext)
-Lateral Costal Expapnsion
-Diaphragmatic Cues
-Segmental Breathing
Thoracic Mobility Exercises to Enhance Inspiration
Explain: I’m going to teach you an exercise to help you expand your ribcage to take larger breaths
Butterfly:
Patient sitting < hands behind your head in a slouched position < bring elbows out as you inhale deeply < exhale normally through mouth as you come back to start
Home exercise:
Patient sitting < hands down by feet in a slouched position < bring arms and chest up as you inhale deeply < exhale normally through mouth as you come back to start
-to expand one side abduct ipsi arm and SB to contra
Thoracic Mobility Exercises to Enhance Expiration
Explain: I’m going to teach you an exercise to help you close your posture to take release breaths out
Butterfly:
Patient sitting < hands behind your head in a slouched position during inhale normally through the nose < bring elbows down by your ears as you exhale with PURSED LIPS < inhale normally through nose as you come back to start
Home exercise:
Patient sitting < inhale trough nose normally < hands down by feet in a slouched position as you exhale through PURSED LIPS < inhale normally through nose as you come back to start
-to expand one side abduct ipsi arm and SB to ipsi too force out air
Postural Drainage
Prone (head down): superior lobes, posterior basal
Sidelying (head down a little): lateral lobes
Supine: anterior lobes, middle lobe
Forward Lean: posterior and superior lobes2
Percussion
Explain: To loosen and remove secretions i’m going to do some cupping and precussion, Show on leg
Position to help gravity drain into larger areas < cup hands and percusses for 15-30s < reasses vitals < repeat 3x < add vibration on exhale < reasses vitals
CONTRAINDICATIONS:
-hemmorage, emoblism, new babies with respiratory issues, subcutaneous emphysema, pneumothorax, bone issues
-COPD: can cause spasms, pursed lip exhalation, more secretions
Vibration
-used on chest wall during exhalation
-can be used when percussion not tollerated
CONTRAINDICATIONS:
-hemmorage, emoblism, new babies with respiratory issues, subcutaneous emphysema, pneumothorax, bone issues
-COPD: can cause spasms, pursed lip exhalation, more secretions
Special Considerations for Airway Clearance with COPD
Percussion can cause spasms, pursed lip exhalation, more secretions
-avoid forced exhalation
-head down might not be tolerated
Coughing
Explain: I’m going to teach you how to prepare and to cough to best clear the lungs of secretions
Position: upright with towel <Teach Thoracic Expansion < hold on inspiration < Recruit abdominals by tightening muscles like preparing for a punch < hunch over and cough into napkin
CONTAINDICATIONS:
-surgical incisions, aortic aneryism, hemmorage, wounds, tolerance
Huffing
Explain: I’m going to teach you another technique when coughing isn’t working. It is more of a forced breath like fogging up your glasses
Sit patient upright with towel < segmental thoracic expansion < hold on inspiration < recruit abs < open mouth on an “O” and huff while flexing trunk
-good for noneffective coughs, COPD less forced exhale
Active Cycle Breathing Technique
Explain: We will combine deep breathing, huffing, and coughing
Relaxed diaphragmatic breathing < gradually breathing deeper (note crackles early are large airways and late are small airways) < Add thoracic expansion < inspire and hold 3s < relaxed exhalation in sigh < 1-2 huffs < if felt in upper airways cough gently < relax breathing
Autogenic Breathing
-self drainage to control mucus
Explain: Self drainage to control mucus
-breathe normally, breath diaphragmatically for 3-4 breaths, exhale completely, inhale maximally, let me know when you feel secretions
Level 1: Unsticking of mucus
-avoid coughing < exhale completely < inhale a small breath and hold 1-3s < repeated until crackles are heard
Level 2: Collecting the mucus
- avoid coughing < slighly larger breath < hold for 1-3s < slight exhale < repeat until crackles heard at the end of exhale < continue for 2-3 more breaths
Level 3: Evacuating mucus
-slow deep breath < hold 1-3s < exhale forcefully in a < spit out secretion < if not, do 2-3 large huffs
Patient Paced Diaphragmatic Breathing (Emphysema)
-allows for ambulation, prevents dypnea, helps with management of dypnea
Explain: I’m going to teach you how to breathe properly during different activities to conserve your energy while we move.
-you will inhale normally and exhale through pursed lips
Supine < Palpate diaphragm and tell to breathe into hand < exhale and PURSE LIPS during transitional mmt (roll to sit) < put on gait belt < show relief position if needed (bend over and breathe into belly) < reminder to pace themselves < walk and guard
Diaphragmatic Breathing (Obstructive/Emphysema))
-ease breathing in a controlled manner
-in all positions
Explain: I’m going to teach you a breathing technique tha focuses on using your diaphragm so you can do less work to breathe
Position patient upright < palpate diaphram and place Pt hand on it and upper chest < instruct them to breath in through the nose REGULARLY and slowly through their mouth with PURSED LIPS < encourage them to feel it more in their belly than chest
Emphysema
-COPD
-Obstructive
-red skin, skinny, pursed lips
-working hard to exhale air, can still oxygenate
-hypercompliant lung balloons alveoli trapping air
Chronic Bronchitis
-COPD
-obstructive
-inflamation of bronchioles obstructing/narrowing airway and increasing mucous
-“blue bloater”
Segmental Thoracic Expansion
-place hand in diaphragm under constal angle < instruct to breathe into hand < place other hand low on sides of ribs < instruct to breathe into hand < place first hand into upper ribs; apical (not sternum) < instruct to breath into hand
CONTRAINDICATIONS:
-pneumothorax, hemmorage
Tracheal Tickling Technique
-if effective cough cannot be produced
-apply digital pressure to trachea, right above sternal notch, move side to side
Tongue out Technique
-if effective cough cannot be produced
-deep breath and stick toungue out before cough
Chest Wall Excursion: Direct Technique
Explain: I’m to place my hands on your shoulders, chest and mid back to see how it expands on each side
-Breathe normally, looking for symmetrical movement
-inhale maximally
Apixal:Palms at upper trap, thumbs meet at clavicles
Middle: palms below nipple line, thumb meet at middle
Posterior Lobe: behind Pt, palms under 10th rib
Chest Wall Excursion: Tape Measure
Explain: I’m to meaure your chest and mid back to see how it expands on each side when breathing
-Breathe normally 1st
-inhale maximally 2nd round
-measure at 3 and average (8.5cm)
Upper: 4th costal cartilage
Middle: xiphoid process
Lower: 9th constal cartilage
Bronchophony
Explain: I’m going to listen your lungs and see how equal the sounds are on both sides while you repeat certain sounds
-chest wall examination using stethoscope
-listen for increased (consolidation) or decreased sounds
-say “Blue moon” and listen to changes in each lobe
Egophony
Explain: I’m going to listen your lungs and see how equal the sounds are on both sides while you repeat certain sounds
-chest wall examination using stethoscope
-listen for increased (consolidation) or decreased sounds
-say “eeeee” and check for shifting sounds to “aaaaa”
Whispered Pectoriloquy
Explain: I’m going to listen your lungs and see how equal the sounds are on both sides while you repeat certain sounds
-chest wall examination using stethoscope from top to bottom and side to side
-listen for increased (consolidation) or decreased sounds
-Whisper “99” and check for differences
Mediate Percussion
Explain: I’m going be tapping my fingers along your chest and back to see if the sounds change from side to side
-strike finger at intercostal spaces anterior and posterioly over each lobe
Expectations:
Resonant (low longer) sounds over the lungs; filled with air
Dull: (higher pitched and shorter) indicate more dense structures/fluid, consoldation
Hyper-resonant: very low pitched and long; decreased tissue (emphysema)
Flat: muscle
Tympanic: high pitched, hollow structures
Diaphragmatic Excursion
Explain: I’m going to tap several parts of your back to listen to how your diaphragm is moving as you breathe
-inhale and hold your breath
-Exhale and hold your breath
-tap down back from T7 and listen to where the resonant sound stops both time
-measure disance (3-5cm norm)
-repeat on other side
Restrictive Lung Diseases
-decreased in vital capacity
-lung compliance reduced and stiffness limits expansion
-lower ventilation
Ex: pneumonia, collapsed lung
Diaphragmatic Breathing (Restrictive)
-ease breathing in a controlled manner
-in all positions
Explain: I’m going to teach you a breathing technique tha focuses on using your diaphragm so you can do less work to breathe
Position patient upright < palpate diaphram and place Pt hand on it and upper chest < instruct them to take a DEEP breath in through the nose and slowly through their mouth in a SIGH < encourage them to feel it more in their belly than chest
Abnormal Breath Sounds
-bronchial sounds
-Decreased/diminished
-Absent
Adventitious Sounds
-Crackles or rales: discontinuous sounds; airway obstruction or restrictive lung diseases
-wheezing: smaller airways, asthma
-stridor: crowing sound, uper airway obstruction
-Pleural rub: rubbing inflamed pleural surfaces agains lung
Diagnosis of Sounds
Pleural Effusion: conta traacheal dev, decreased sounds, dull percussion (stuff)
Consolidation: increased fremitus and pectoriloquy, decreased breath sounds, dull percussion, bronchial sounds
Emphysema: decreased fremitus, hyper resonant percussion, decreased pectoriloquy, crackles
Tension Pneumonthorax:
-contra tracheal dev, hyper resonant percussion, decreased breath sounds
Mucus Plug w/ Collapse: ipsi tracheal dev, decreased everything, dull percussion
