Chapter 16 Bedside Assessment of the Patient

What is the difference between a stuperous patient and a comatose patient?

Stuporous patients do not wake up completely. They do respond to pain and may respond slowly to verbal stimulus. Comatose patients are unconscious and have loss of reflexes and other response to stimuli. They usually do not move voluntarily.

How does subcutaneous emphysema form? What is the feeling of air under the skin called?

Subcutaneous air forms when air leaks from the lung and gets under the tissue layers of the skin. The crackling sensation is called crepitus.

describe the dyspnea (Borg) scale. list several reasons why this scale would be useful

The Borg scale is useful because it quantifies the level of dyspnea. The scale asks the patient to rate his or her dyspnea from 1, least, to 10, worst. Because this is a subjective symptom, the scale allows us to get valuable information and compare how a person responds to therapists. Research indicates patient perception of difficulty breathing is valid and clinically useful.

What is the first thing a respiratory therapist should evaluate in cases of a depressed level of consciousness?

The RT should assess oxygenation(of course they also make sure the patient is alive!)

What do the initials PMH stand for? List at least five important areas described in the PMH. A. PMH=

A. PMH= Past medical history 1. Childood diseases 2. Hospitalizations (injuries, major illness) 3. Medication allergies 4. Surgeries 5. Drugs/medications

Chapter 16 objectives

1. Describe why patient interviews are necessary and the appropriate techniques for conducting an interview. (Q: 21,22,23, 24) 2. Identify abnormalities in lung function associated with common pulmonary symptoms. (Q:26,27,,28, 76,77, 78,79,80, 81, 82) 3. Identify breathing patterns associated with underlying pulmonary disease. (Q 47, 52) 4. Differentiate between dypsnea and breathlessness( Q: 19, 20) 5. Identify terms used to describe normal and abnormal lung sounds (Q:67) 6. Describe the mechanisms responsible for normal and abnormal lung sounds(Q:67) 7. Explain why it is necessary to examine the precordium, abdomen, and extremities, in patients with cardiopulmonary disease. (Q: 70,71,72) 8. Describe some of the common abnormalities found during the examination of the precordium, abdomen, and extremities in patients with cardiopulmonary disease. ( Q: 51, 52, 53,54,56, 57, 58, 58, 59, 60, 61, 62, 63, 64)

Describe the significance of the findings for each of areas of general appearance listed below. 1. Weak, emaciated, and diaphoretic 2. Appears anxious 3. Sitting up, leaning with arms on table

1. weak, emanciated, and diaphoretic- general ill health and malnutrition; fever, stress, acute anxiety 2.Appears anxious- severity of problem; level of cooperation 3. Sitting up, leaning with arms on table- typical position for patients with obstructive lung diseases who are having trouble breathing

Complete the following chart by identifying the percussion notes for the conditions. A. emphysema B. Atelectasis C. Pleural effusion D. Pneumothorax E. Pneumonia

A Emphysema- increased resonance (hyper resonant) B Atelectais- decreased resonance (dull or flat) C. Pleural effusion- decreased resonance (dull or flat) D. Pneumothorax- Increased resonance (hyperresonant or tympanic) E. Pneumonia- Decreased resonance (dull or flat)

Describe how to start the ideal interview. Be sure to discuss space, privacy, and introductions. A. Social B. Privacy C. Introductions

A. Space- 4 to 12 ft to start. Move closer and try to get at eye level. B. Privacy: Use the curtain if it is not a private room. C. Introductions: Identify yourself and your purpose: identify the patient.

What do the initials CC and HPI stand for? List at least five important areas described in the HPI. A. CC= B. HPI=

A. CC=chief complaint B. HPI= history of present illness 1.onset, frequency, and duration of symptoms 2. Location of pain 3. Quality of pain 4.Aggravating and alleviating factors 5. Associated manifestations

What are the three characteristics of sputum that should be documented and reported to the physician and other members of the health care team.

A. Color B. Viscosity( thick, thin, sticky, etc.) C. Quantity (small, copious, or by volume)

along with fever, what are two signs that are highly suggestive of respiratory infection?

A. Cough B. Purulent sputum

What are the possible causes of these common types of cough? A. Dry B. Loose, Productive C. Acute, self-limiting D. Chronic

A. Dry- Restrictive: congestive heart failure (CHF), fibrosis B.Loose, productive: Inflammation: asthma, chronic obstructive pulmonary disease. C. Acute, self-limiting: Viral respiratory infection D. Chronic: Gastroesophageal reflux disease, nasal drip, asthma, medication

Fill in the correct normal values (or terms) for an adult in the chart below

A. Temperature avg. normal 98.6 lowest normal hypothermia highest normal hyperthermia B. Heart Rate avg. normal 72 beats per min lowest normal 60; below 60 bradycardia highest normal 100; above 100 tachycardia C Respiratory Rate avg. normal 12 to 18 breaths/min lowest normal below 10 bradypnea highest normal above 20 tachypnea D Systolic blood pressure avg. normal 120 mmHg lowest normal 90 mmHg, below 90 hypotension highest normal 140 mmHg above 140 hypertension E. Diastolic blood pressure avg. normal 80 mmHg lowest normal 60 mmHg below 60 hypotension highest normal 90mmHg above 90 hypertension

Breath Sound A. Vesicular B. Bronchial C. Bronchovesicular

A. Vesicular - pitch low -intensity soft - location peripheral lung B. Bronchial - pitch high -intensity loud - location over the trachea C. Bronchovesicular - pitch moderate -intensity moderate -location Upper chest, between scapulae

During an interview, the patient states he has been coughing up thick, foul smelling sputum. This finding is most consistent with A. a bacterial infection in the lung B. A diagnosis of lung cancer C. obstructive lung disease D. pulmonary tuberculosis

A. a bacterial infection in the lung

Write a description for the following six abnormal chest shapes. A. Barrel B. Kyphosis C. Kyphoscoliosis D. Pectus carinatum E Pectus excavatum F.scoliosis

A.Barrel- increased anteroposterior (AP) diameter B. Kyphosis- Abnormal AP curvature of the spine C. Kyphoscoliosis- Combination of kyphosis and scoliosis D. Pectus Carinatum- abnormal protrusion of the sternum E Pectus excavatum- abnormal depression of the sternum F. Scholiosis- Abnormal lateral curvature of the spine

Answer the following questions about cyanosis. A. What is the specific cause of cyanosis ? B. What is peripheral cyanosis? C. What is the main cause of peripheral cyanosis?

A.What is the specific deoxygenation- deoxygenation of hemoglobin B. What is peripheral cyanosis- Peripheral cyanosis presents with bluish color on the extremities C. What is the main cause of peripheral cyanosis? Peripheral cyanosis is most often caused by poor circulation.

Circle the best approach from each set of choices in the following list: A1 What are you coughing up? A2 You didn't cough up blood, did you? B1 I understand you don't like your breathing treatments B2 Why don't you like these treatments? C1 How is your breathing today? C2 Is your breathing better today?

A1 What are you coughing up? B1 I understand you don't like your treatments C1 How is your breathing today?

Circle the best approach from each set of choices in the following list: A1. Hi, Bob, good morning A2. Good morning Mr.Johnson B1 Stand at the foot of the bed B2 Sit in a chair at the bedside. C1 Make room for your notes on your bedside table. C2 Keep your clipboard on your lap. D1 Do you need anything right now? D2 I'll tell the nurse to check on you. E1 I'll be back to see you in one hour E2 I'll return in a while to check on you.

A2 good morning Mr. Johnson B2 sit in a chair at bedside C2 Keep your clipboard on your lap D1 Do you need anything right now? E1 I'll be back to see you in 1 hr.

What are the limitations of percussion? What can't you palpate?

Abnormalities that are small or deep cannot be easily detected.

What does the phrase oriented x 3 mean?

An alert, well-oriented person knows who they are, where they are, and the time or day.

There are vibrations on exhalation over the upper chest. What action should be taken at this time? A. The patient should be given a bronchodilator B. The patient should be suctioned C. The patient should be given supplemental oxygen D. The patient should be placed on mechanical ventilation.

B. The patient should be suctioned

A child is brought is to the emergency department for severe respiratory distress. Upon entering the room, the RT hears a high-pitched sound when the child inhales. This is most likely A.wheezing B. stridor C. Rhonchi D. crackles

B. stridor

A 59 year old rock star is recovering from open heart surgery performed 2 days earlier. He is alert and oriented x 3. He complains of dyspnea and a dry cough. Vital signs reveal a pulse of 104 beats/min and a respiratory rate of 32 breaths/min with a shallow pattern. The patient tells you that his difficulty breathing started yesterday and has been gradually getting worse. Auscultation reveals decreased breath sounds in both cases with end-inspiratory crackles. What respiratory care intervention(s) is indicated?

Because the patient has dyspnea, cough, tachypnea, and tachycardia, he may have hypoxia. Oxygen (O2) may be indicated Assess with pulse oximeter and possibly arterial blood gas. If the chest radiograph shows atelectasis, a lung inflation procedure like IS may be indicated.

A 47 year old female is admitted for a systemic infection 3 days after cutting herself in the kitchen while preparing some chicken. She complains of dypsnea and has a fever. Her vital signs are pulse 110 beats/min, respiratory rate 28 breaths/min, and blood pressure 76/58 mmHg. The nurse's note reveal that the patient was alert on admission, but she is now confused and anxious. Her extremities are warm and capillary refill is normal. Which abnormal vital sign has the most clinical significance in this case?

Blood Pressure

An Rt is is inspecting the chest of a child with respiratory distress. The practitioner notes that the child has a large concave depression of the sternum. This finding should be documented as A. barrel chest B. pectus carinatum C. pectus excavatum D. kyphoscoliosis

C. pectus excavatum

Describe the difference between fremitus in emphysema and in pneumonia.

Emphysema causes decreased fremitus because hyperinflation. Pneumonia usually increases the intensity of fremitus because of consolidation.

A 59 year old rock star is recovering from open heart surgery performed 2 days earlier. He is alert and oriented x 3. He complains of dyspnea and a dry cough. Vital signs reveal a pulse of 104 beats/min and a respiratory rate of 32 breaths/min with a shallow pattern. The patient tells you that his difficulty breathing started yesterday and has been gradually getting worse. Auscultation reveals decreased breath sounds in both cases with end-inspiratory crackles. What diagnostic test is indicated to confirm the diagnosis?

Chest radiograph

When are closed questions most useful? Give an example

Closed questions are useful when you want specific information or want to clarify something. "How long did the pain last? How much did you cough up?

Compare the mechanisms and causes of course, low pitched crackles and fine, end-inspiratory crackles.

Coarse, low-pitched crackles are often caused by secretions being moved by air in the airways. Fine, end-inspiratory crackles are probably caused by sudden opening of peripheral airways and are associated with restrictive disorders like fibrosis, atelectasis, and pulmonary edema.

How can you prevent patients from becoming aware (and consciously altering) that you are taking their respiratory rate?

Count their respiratory immediately after the pulse, while keeping your fingers on the wrist.

A patient's medical record indicates that he has orthopnea. Which of the following best describes this condition? A. difficulty breathing at night. B. Difficulty breathing when upright C. Difficulty breathing on exertion D. Difficulty breathing when lying down

D. Difficulty breathing when lying down

An Rt is asked to evaluate a patient a patient for oxygen therapy. She notices that the patient is sleepy but arouses when questioned. This level of consciousness is best described as A. confused B. obtunded C. stuporous D. lethargic

D. lethargic

How else can you identify the degree of dyspnea a patient feels? Explain the difference between dyspnea and breathlessness.

Identify the level of exertion (activity) associated with dyspnea. Dyspnea is the sensation of difficulty breathing. Breathlessness means you feel like you are not getting enough air. The text elaborates.

presence of a fever

febrile

How do you test for capillary refill? What is a normal capillary refill time?

It is assessed by pressing briefly on the fingernail. Normal refill time is less than 3 sec.

Compare and contrast the terms lethargic and obtunded

Lethargic refers to a sleepy patient who is easily aroused and responds appropriately when aroused. Obtunded patients are difficult to arouse but still respond appropriately once aroused.

Contrast monophonic and polyphonic wheezes in terms of mechanisms, phase of ventilation, and conditions that produce these different muscle sounds.

Monophonic wheezes indicate indicate a single obstructed airway. The wheezing may be heard on inspiration or expiration. Mucus or a foreign object might be the cause. Polyphonic wheezes suggest multiple obstructed airways and are first heard on exhalation. As the patient worsens they may be on inspiration and expiration, or in severe cases only on inspiration and expiration, or in severe cases only on inspiration. They are most likely to be caused by bronchospasm or CHF.

What is the difference between mucus and sputum?

Mucus is normally produced by healthy airways. When the amount of mucus is increased and expectorated, it is called sputum.

An alert 67 year old politician is admitted for dyspnea and hemoptysis. While interviewing the patient you discover that he has been coughing up small amounts of thick, blood streaked mucus several times per day for the last few days. He has a history of 100 pack years of cigarette smoking. Physical examination revels a barrel chest, use of accessory muscles, and digital clubbing. The patient's history and chest configuration suggest what primary pulmonary disorder?

Obstructive lung disease, possibly chronic bronchitis

What does it mean when patients show a lager(> 6 to 8 mmHg) than normal drop in a systolic pressure during inspiration?)

Paradoxical pulse is present. It is caused by decrease in intrathoracic pressure during inspiration. This is usually caused by hyperinflation, such as asthma or cardiac restriction from tamponade.

What information would you gather before entering the patient's room?

Read the patient's medical record to determine history of present illness, chief complaint, past medical history, family/environmental history, and the systems review.

significant elevation of temperature will have what result on a metabolic rate, oxygen consumption, carbon dioxide production, and breathing pattern?

Significant temperature elevations will elevate all of these.

Where should you check for edema caused by heart failure ? Why?

Usually the feet and legs are checked. Fluid settles there due to gravity.

Explain the difference between vocal and tactile fremitus

Vocal: Vibration produced by speech Tactile: Vibration that an be felt.

Match these respiratory patterns to their definitions a. Tachypnea b. Eupnea c. Platypnea d. Hyperpnea e. Bradypnea

a. Tachypnea-abnormally high respiratory rate b. Eupnea- normal breathing pattern c. Platypnea- defficulty breathing in supine position d. Hyperpnea- labored breathing in an upright position e. Bradypnea-abnormally low respiratory rate

Chest pain typical of acute coronary syndromes

angina

What is the most serious kind of nonpleuristic chest pain?

angina, which may be a symptom of heart disease or acute coronary syndrome, is the most serious kind of nonpleuritic chest pain. Esophageal tissues are the number two cause of chest pain in the emergency department and most confused with myocardial infarction.

A 59 year old rock star is recovering from open heart surgery performed 2 days earlier. He is alert and oriented x 3. He complains of dyspnea and a dry cough. Vital signs reveal a pulse of 104 beats/min and a respiratory rate of 32 breaths/min with a shallow pattern. The patient tells you that his difficulty breathing started yesterday and has been gradually getting worse. Auscultation reveals decreased breath sounds in both cases with end-inspiratory crackles. What is the most likely cause of dyspnea

atelectasis which is likely based on the history of recent surgery , crackles and dry cough

Shape of thorax associated with emphysema

barrel chest

a slow heart rate that may result in poor perfusion of tissues

bradycardia

sensation of suffocation

breathlessness

physical wasting associated with chronic lung disease

cachexia

Inspiratory sounds associated with atelectasis , pneumonia , and fibrosis

crackles

bluish discoloration of skin often associated with hypoxemia

cyanosis

difficulty breathing

dypsnea

An alert 67 year old politician is admitted for dyspnea and hemoptysis. While interviewing the patient you discover that he has been coughing up small amounts of thick, blood streaked mucus several times per day for the last few days. He has a history of 100 pack years of cigarette smoking. Physical examination revels a barrel chest, use of accessory muscles, and digital clubbing. What does the presence of clubbing suggest in this case?

lung cancer is a possible cause

Difficulty breathing when lying supine

orthopnea

A 47 year old female is admitted for a systemic infection 3 days after cutting herself in the kitchen while preparing some chicken. She complains of dypsnea and has a fever. Her vital signs are pulse 110 beats/min, respiratory rate 28 breaths/min, and blood pressure 76/58 mmHg. The nurse's note reveal that the patient was alert on admission, but she is now confused and anxious. Her extremities are warm and capillary refill is normal. What other vital signs should be evaluated?

oxygenation. there is evidence of hypoxia. Pulse oximetry to assess oxygenation may or may not be useful with low bloodpressure, but it should be initiated anyway. A blood gas may be needed.

How does pleuristic chest pain differ from nonpleuristic pain?

pleuristic pain is usually located laterally or posterior. It is a sharp, stabbing pain associated with pneumonia, pulmonary embolism, and pleural disease that worsens on inspiration. Nonpleuritic (angina) chest pain is usually located in the center of the chest and may radiate. Chest wall pain, gallbladder disease, reflux, and esophageal spasm are causes other than cardiac disease. Angina doe not vary with inspiration.

heart rate auscultated in chest is different than pulse rate felt in arm

pulse deficit

difference between systolic and diastolic blood pressure

pulse pressure

drop in blood pressure on inhalation associated with asthma and hyperinflation

pulsus paradox

soft tissue sucking in around ribs and neck when a patient has severe distress.

retractions

Blood pressure that is too low

shock

A 47 year old female is admitted for a systemic infection 3 days after cutting herself in the kitchen while preparing some chicken. She complains of dypsnea and has a fever. Her vital signs are pulse 110 beats/min, respiratory rate 28 breaths/min, and blood pressure 76/58 mmHg. The nurse's note reveal that the patient was alert on admission, but she is now confused and anxious. Her extremities are warm and capillary refill is normal. Why do you think the patient's mental status has deteriorated?

shock(low blood pressure) causing poor cerebral perfusion is likely due to perfusion,, but may be present for other reasons.

An alert 67 year old politician is admitted for dyspnea and hemoptysis. While interviewing the patient you discover that he has been coughing up small amounts of thick, blood streaked mucus several times per day for the last few days. He has a history of 100 pack years of cigarette smoking. Physical examination revels a barrel chest, use of accessory muscles, and digital clubbing. Along with enlargement of the ends of the fingers, what sign helps you recognize clubbing?

sponginess of the nail, altered angles

upper airway sound that may indicate life-threatening obstruction

stridor

dizziness associated with a drop in blood pressure

syncope

a rapid heart rate that may indicate a low blood oxygen level

tachycardia

The sitting position that emphysema patients use when they are in trouble

tripodding

Musical inspiratory or expiatory sound associated with asthma

wheezes