Respiratory Exam Flashcards
When conducting a respiratory exam what state of undress would the patient ideally be in?
A skin level - Top is required to be off
Can be conducted with top on if patient is uncomfortable, but makes it VERY difficult to do certain assessments without assistance
First step in a respiratory assessment?
Ask the patient to take a deep breath in - note any pain and observe if the chest wall is symmetrical in its movement
What should you first inspect the anterior chest for when beginning a respiratory exam?
Symmetrical movements
Shape - deformities
Scars
What deformities are you most likely to see on the anterior chest during a respiratory exam?
Pectus Carinatum (pigeon chest)
Pectus Excavatum (funnel chest)
Barrel chest
What deformities are you most likely to see on the posterior chest during a respiratory exam?
Deformities of the spine; Scoliosis and Kyphosis
What deformity can be observed here?
Pigeon chest (Pectus Carinatum)
What is Pectus Carinatum (pigeon chest)?
where the sternum protrudes outwards further than the ribs
What deformity can be observed here?
Funnel chest (Pectus Excavatum)
What is Pectus Excavatum (funnel chest)?
a funnel shaped depression on all or part of the sternum
What deformity can be observed here?
Barrel chest
What causes barrel chest to form?
A barrel chest forms because your lungs are chronically overfilled with air and can’t deflate normally.
This causes your rib cage to be partially expanded at all times.
What condition is barrel chest commonly observed in?
COPD
What deformity can be observed here?
Scoliosis - the sideways curvature of the spine
What deformity can be observed here?
Kyphosis - forward curvature of the spine
Why is it important to look for certain deformities in patients when conducting a respiratory exam?
Can impact cardiopulmonary function due to the displacement of organs in the thorax
Why should you look for scars when conducting a Respiratory exam?
Scars can indicate previous cardiac or respiratory insufficiencies, which may affect respiratory function
What could a scar under the left clavicle indicate?
Pacemaker
Implantable cardioverter-defibrillator
What could a scar down the centre of the chest indicate?
Previous heart surgeries such as CABG (coronary access bypass graft)
What could a scar in the axillar region indicate?
Previous chest drains
What could a scar dow the posterior of the chest indicate?
Previous lung surgeries
Where is the axillar region?
Pertaining to the armpit area, including the lymph nodes that are located there
When physically assessing for asymmetry would you assess the anterior or posterior of the patient?
Posterior
How would you test for symmetry in chest expansion?
On the patients posterior
Place both hands on the patients back - equal on both sides
Ask the patient to take a deep breath - assess if your hands move equally apart symmetrically
You assess for symmetrical chest expansion, if asymmetry is observed what could this indicate?
Tension pneumothorax
Paradoxical movement
What is paradoxical movement?
Where a segment of the chest wall moves in the opposite direction to the rest of the chest - for example in flail chest
When assessing a patients pattern of breathing what 5 things would you note?
Respiration rate
Rhythm
Depth
Accessory muscle usage
Audible sounds
What is considered a normal respiration rate for adults?
Between 12-20 regular and even respirations
How would you assess a patients respiration rate?
Count for 15 seconds and multiply by 4 to achieve a number of respirations across a full minute
What respiration rate indicates tachypnoea?
More than 20-25 per minute
When would you commonly observe tachypnoea?
Various lung diseases/conditions
Patients in pain
Anxiety
Infection
What respiration rate indicates bradypnoea?
RR of less than 12 per minute
When would you commonly observe bradypnoea?
Patients with depression of the brains respiratory control centre - such as in diabetic coma, excessive sedation and those who have ingested opiate based analgesia
What pattern of breathing would indicate Cheyenne Stokes respirations?
a pattern of fast, shallow breathing followed by slow, heavier breathing and moment without any breathing at all
When would Cheyenne Stokes respirations commonly be observed?
often observed in heart failure but irregular breathing patterns can indicate raised intercranial pressure, such as within strokes.
When assessing a patients depth of breathing what are you observing for, why?
Too shallow or too deep can indicate respiratory distress
If accessory muscle usage is present what could this indicate?
An increased work of breathing
What audible sounds should you be listening for during a respiratory exam?
Stridor
Wheeze
What conditions commonly cause stridor?
caused by an upper respiratory obstruction; commonly heard in croup and epiglottis
What condition commonly causes a wheeze?
Narrowing of the airway and bronchospasm
Acute asthma exacerbation
COPD
In what ways do we measure anterior chest expansion?
Manually and using tape
How do you manually measure chest expansion?
Place both hands equally on anterior chest
Ask the patient to take a deep breath in
Feel that the chest is moving an expected amount and is expanding equally on both sides
When manually measuring chest expansion, you note that the chest is moving unequally, what does this indicate?
There is reduced or absent air entry on the side of the chest that is not moving as much - for example in tension pneumothorax
Would also be observed in patients with only one lung
How do you assess a numerical representation of chest expansion?
Place the tape measure 1cm below the nipple line, all the way round the patient
Ask the patient to relax and breathe out
Tight to the skin, note the value in cm
Ask the patient to take a deep breath in and note the new value in cm
Note the difference in cm
How many cm is considered a normal chest expansion value?
4-5cm
When would you expect to find an increased chest expansion value?
Well conditioned persons with a greater lung capacity
When would you expect to find a decreased chest expansion value?
COPD
Asthma
Those suffering with pain - e.g. pleuritic rub
When palpating the trachea what are you checking?
That the trachea is straight and in the mid-line position
If the trachea is found to be deviated, what could this indicate?
Tension pneumothorax
Tumour or mass that is pressing on the trachea - although this would be palpable
How do you palpate for tracheal tug?
Place one finger in the suprasternal notch
Ask the patient to take a deep breath
If the patient was in respiratory distress, the cricoid should pull down and hit the back of the finger due to the downward pull of the trachea when a deep breath is taken
When might you observe tracheal tug in a patient?
When a patient is in respiratory distress
What is being shown in this picture?
suprasternal notch
When palpating the anterior chest what landmarks should you consider?
Ribs
Intercostal space
Down the sternum
When palpating the anterior chest what are you looking for?
Pain/tenderness
Abnormal lumps
Deformities
Crepitus
What could pain on palpation of a rib indicate?
A potential fracture or break
What would the palpation of crepitus indicate?
Subcutaneous emphysema - Subcutaneous air in the chest
What does subcutaneous emphysema feel like on palpation?
Often be seen as a smooth bulging of the skin
When the skin is palpated, it produces an unusual crackling sensation (crepitus) as the gas is pushed through the tissue
Which nodes should you palpate on the anterior chest?
Supraclavicular
Infraclavicular
Axilla
What would you expect to feel in a healthy individual when palpating their lymph nodes?
Nothing
When palpating the supraclavicular
and infraclavicular lymph nodes you are able to palpate some of the nodes, what could this indicate?
I would expect some sort of infection or malignancy somewhere in either the chest or abdominal cavity
If left axillary lymph nodes are palpable, what could this indicate in women?
Breast pathologies
Women should be referred for a breast examination
Where are the supraclavicular lymph nodes located?
a set of lymph nodes found just above the clavicle or collarbone, toward the hollow of the neck
Where are the infraclavicular lymph nodes located?
are found beside the cephalic vein, between the pectoralis major and deltoideus, immediately below the clavicle
How do you palpate the posterior chest for nodes, lumps, tenderness
There are no nodes located on the posterior chest, so I am assessing for pain, tenderness and abnormalities. I am feeling down the ribs, intercostal spaces and spine again.
Posterior or anterior chest assessment when assessing a patients tactile vocal fremitus?
Both
What does the presence of tactile vocal fremitus indicate?
the vibration of the chest wall that results from sound vibrations created by speech or other vocal sounds
How would you assess a patients tactile vocal fremitus?
Using the ulnar aspect of your hand
Place hands equally on each side of the rib cage and ask the patient to say 99 - each time reposition your hands further down the patients chest/back
What positional change would you make when checking for tactile vocal fremitus posteriorly?
Ask the patient to hug a pillow or cross arms over chest
When assessing a patients tactile vocal fremitus you note that the vibrations are not felt equally on both sides and noticeably increase when moving down the chest - what could this indicate?
Indicate consolidation - for example in pneumonia or in the presence of a tumour due to vibrations travelling better through solids/liquids
When assessing a patients tactile vocal fremitus you note that the vibrations are reduced- what could this indicate?
can indicate excess air in the chest, for example with a tension pneumothorax or hyperinflation of the chest
although you would expect the patient to appear more unwell
Which parts of the chest should you percuss during a respiratory exam?
Clavicles
Anterior chest
Posterior chest
When percussing a patients chest what are you listening for?
Normoresonance should be heard
Ruling out any hypo/hyper-resonance
When percussing a patients chest what could hypo-resonance indicate?
abnormal dull sound and is indicative of consolidation in the lungs
Could be due to pus and mucus from pneumonia or fluid from LVF heart failure
When percussing a patients chest what could hyper-resonance indicate?
Indicates excess air in the chest
Can be indicative of a tension pneumothorax, acute asthma or emphysema
In relation to the lungs where do the clavicles sit?
Covers the apexes of the lungs
In how many locations should you percuss the anterior chest?
4 locations (8 total)
3 Down the mid-clavicular line and one on either side, ensuring to percuss all lung lobes
When percussing the anterior of the chest you note dullness on the left of the sternum around the 3rd and 4th intercostal space, why is this?
The heart
In how many locations should you percuss the posterior chest?
4 locations medially
Why do you percuss the posterior chest in 4 locations?
The lungs extend further down
When percussing the posterior chest you ask the patient to hug a pillow, why Is this?
Displaces the scapula allows for better access to the lungs rather than the bone
When auscultating a patients chest what are you checking for?
Normal vesicular breath sounds
What are some common adventitious breath sounds you may hear when auscultating a chest?
Wheeze
Crackles
Pleural rub
What could a wheeze on auscultation indicate?
A wheeze is the result of airflow being partially blocked or narrowed - commonly in acute asthma exacerbation and bronchitis
What could crackles on auscultation indicate?
Crackles are a result of air passing through fluid or collapse or fluid-filled alveoli popping open in conditions - such as pneumonia and heart failure (LVF)
What could pleural rub on auscultation indicate?
pleural rub - caused by inflamed pleural membranes rubbing together
When auscultating a patients chest should you ask them to breath through their mouth or nose?
Mouth
Why do we check for spoken resonance and whispered resonance?
Helps to identify any areas of consolidation in the lungs - whispered resonance allows for more precise identifying of subtle changes
How do you assess for spoken/whispered resonance?
Ask the patient to say 99 out loud each time you place your stethoscope down in a new position.
Then ask the patient to whisper 99
When auscultating and percussing anterior chest how many positions do we percuss?
3 down and 2 at the sides - each side
When auscultating and percussing posterior chest how many positions do we percuss?
5 down and 2 at the sides - each side
What would you expect to hear in a healthy individual when testing for vocal resonance?
If clear loud sounds are heard it can indicate underlying consolidation - such as pneumonia or any solid masses such as a tumour
Why does consolidation within the chest increase the volume of vocal resonance heard?
Sound and vibrations travel more readily through fluids and solids
What final assessment is performed last in a respiratory exam?
Percussion for diaphragmatic excursion bilaterally
Explain the process of percussing for diaphragmatic excursion?
Percuss down the scapula line until the sound changes from resonant to dull
Allow the patient to take a few normal breaths.
Then, ask the person to “take a deep breath and hold it.” Continue percussing down from the first mark, (you should hear resonance) to the level where the sound changes to dull.
Mark the area and measure the distance between the two marks.
Repeat on both sides
What does reduced diaphragm excursion indicate?
can indicate poor lung function for example in emphysema, pain, pleural effusion or diaphragmatic paralysis.
What does increased diaphragm excursion indicate?
occurs in a well-conditioned person with increased lung capacity.
What is diaphragmatic excursion?
The movement of the thoracic diaphragm during breathing
What is considered a normal value of diaphragmatic excursion?
3-5cm
Why might the level of the diaphragm be higher on the right side?
Because of the liver
