RET 1024 Introduction to Respiratory Therapy

1. RET 1024Introduction to Respiratory Therapy Module 4.2 Bedside Assessment of the Patient Inspection

2. Bedside Assessment of the Patient Systematic Examination Thorax and Lungs • The physical examination of the chest and lungs should be performed in a systematic and orderly fashion – the most common sequence is as follows: • Inspection • Palpation • Percussion • Auscultation

3. Bedside Assessment of the Patient Systematic Examination Thorax and Lungs • Topographic landmarks of the lung and chest

4. Bedside Assessment of the Patient Systematic Examination Thorax and Lungs • Topographic landmarks of the lung and chest

5. Bedside Assessment of the Patient Systematic Examination Thorax and Lungs • Topographic landmarks of the lung and chest

6. Bedside Assessment of the Patient Systematic Examination Thorax and Lungs • Topographic landmarks of the lung and chest

7. Bedside Assessment of the Patient Systematic Examination Thorax and Lungs • Topographic landmarks of the lung and chest

8. Bedside Assessment of the Patient Systematic Examination Thorax and Lungs • Topographic landmarks of the lung and chest Left oblique fissure Left upper lobe Left lower lobe

9. Bedside Assessment of the Patient Systematic Examination Thorax and Lungs • Topographic landmarks of the lung and chest

10. Bedside Assessment of the Patient • Inspection • Dyspnea • Abnormal ventilatory pattern • Use of accessory muscles of inspiration • Pursed-lip breathing • Substernal or intercostal retractions • Nasal flaring • Splinting due to chest pain

11. Bedside Assessment of the Patient • Inspection • Abnormal extremity findings: • Altered skin color • Digital clubbing • Pedal edema • Capillary refill • Distended neck veins • Tracheal deviation • Cough (note characteristics) • Sputum production • Hemoptysis

12. Bedside Assessment of the Patient • Dyspnea; shortness of breath as defined by the patient • Patient’s sense that their work of breathing is excessive for their level of activity • Shortness of breath becomes a concern when the drive to breathe is excessive or when the work of breathing increases

13. Bedside Assessment of the Patient • Dyspnea • Drive to breatheis excessive • Hypoxemia • Acidosis • Fever • Exercise • Anxiety

14. Bedside Assessment of the Patient • Dyspnea • Increased work of breathing • Narrowed airways, e.g., • Asthma • Bronchitis • Lung become difficult to expand, e.g., • Pneumonia • Pulmonary edema • Chest wall abnormality

15. Bedside Assessment of the Patient • Dyspnea • Positional • Reclining – Orthopnea • CHF • Bilateral diaphragmatic paralysis • Upright - Platypnea

16. Bedside Assessment of the Patient • Dyspnea • Patient’s description of their dyspnea “My chest is tight” “My breathing is too fast” “I feel like I’m suffocating”

17. Bedside Assessment of the Patient • Inspection • Abnormal Ventilatory Pattern • Provide reliable clues about underlying pulmonary problem • Rapid shallow breathing (Rate with a VT ) • Caused by  lung volume and/or  lung compliance (CL) • Atelectasis • Pneumonia • Pulmonary edema • Pleural effusion • Pneumothorax • Adult respiratory distress syndrome (ARDS)

18. Bedside Assessment of the Patient • Inspection • Abnormal Ventilatory Pattern • Prolonged exhalation time ( Rate with a  VT ) • Caused by  airway resistance (Raw) • Cystic fibrosis • Brochiectasis • Asthma • Bronchitis • Emphysema

19. Bedside Assessment of the Patient • Inspection • Abnormal Ventilatory Pattern • Prolonged inspiratory time • Upper airway obstruction – extrathoracic • Epiglotitis • Croup • Extrathoracic tumor

20. Bedside Assessment of the Patient • Inspection • Use of accessory muscles • During the advanced stages of chronic obstructive pulmonary disease (COPD), the accessory muscles of inspiration are activated when the diaphragm becomes significantly depressed by the increased residual volume (RV) and functional residual capacity (FRC) • Accessory muscles of inspiration • Scalene • Sternocleidomastoid • Pectoralis major • Trapezius

21. Bedside Assessment of the Patient • Inspection • Use of accessory muscles • Accessory muscles of expiration • Recruited when airway resistance becomes significantly elevated • Rectus abdominis • External obliques • Internal obliques • Transversus abdominis

22. Bedside Assessment of the Patient • Inspection • Use of accessory muscles

23. Bedside Assessment of the Patient • Inspection • Pursed-lip Breathing • Occurs in patients during the advanced stages of obstructive pulmonary disease • Patient exhales through lips that are held in position similar to that used for whistling or blowing trough a flute • Retarding the airflow through the pursed lips provides the airway with some stability - offsets early airway collapse

24. Bedside Assessment of the Patient • Inspection • Pursed-lip Breathing

25. Bedside Assessment of the Patient • Inspection • Retractions • Caused by a greater than normal negative intrapleural pressure during inspiratory efforts to overcome low lung compliance as seen in patients with severe restrictive lung disorders, e.g., pneumonia, ARDS, and in premature newborns with surfactant deficiencies or idiopathic respiratory distress (IRDS) • Sternal • Intercostal • Supraclavicular • Subcostal

26. Bedside Assessment of the Patient • Inspection • Retractions Supraclavicular retractions Sternal retractions Intercostal retractions Subcostal retractions

27. Bedside Assessment of the Patient • Inspection • Nasal Flaring • Often seen during inspiration in infants experiencing respiratory distress • Provides a larger orifice for gas to enter the lungs during inspiration

28. Bedside Assessment of the Patient • Inspection • Splinting Due to Chest Pain • Pleuritic Chest Pain • Sudden sharp, stabbing type pain located laterally or posteriorly • Worsens with deep breath • Origin may be from: • Chest wall • Muscles • Ribs • Diaphragm • Mediastinal structures • Intercostal nerves • Parietal pleura (pleurisy)

29. Bedside Assessment of the Patient • Inspection • Splinting Due to Chest Pain • Pleuritic Chest Pain • A characteristic feature of the following respiratory diseases: • Pneumonia • Pleural effusion • Pneumothorax • Pulmonary infarction • Lung cancer • Pneumoconiosis • Fungal diseases • TB

30. Bedside Assessment of the Patient • Inspection • Splinting Due to Chest Pain • Nonpleuritic Chest Pain • Described as constant “dull ache” or “pressure” located in the center of the anterior chest, may radiate to the shoulder • Associated with the following disorders: • Myocardial ischemia • Pericardial inflammation • Pulmonary hypertension • Esophagitis • Local trauma or inflammation of the chest cage, muscles, bones, or cartilage

31. Bedside Assessment of the Patient • Inspection • Abnormal Chest Configuration • During inspection the respiratory care practitioner systematically observes the patient’s chest for both normal and abnormal findings • Is the spine straight? • Are any lesions or surgical scars evident? • Are the scapulae symmetric?

32. Bedside Assessment of the Patient • Inspection • Abnormal Chest Configuration • Anteroposterior (AP) diameter •  Slightly with age and prematurely with COPD Barrel Chest – In the normal adult, the AP diameter of the chest is about half its lateral diameter (1:2). When the patient has barrel chest, the ration is (1:1) - associated with emphysema

33. Bedside Assessment of the Patient • Inspection • Abnormal Chest Configuration Pectus excavatum Pectus carinatum – funnel-shaped depression over the lower sternum (aka: “funnel chest”) -associated with restrictive lung defects – forward projection of the xiphoid process and lower sternum (aka: “pigeon breast”

34. Bedside Assessment of the Patient • Inspection • Abnormal Chest Configuration Kyphosis Scoliosis A “hunchbacked” appearance caused by curvature of the spine A lateral curvature of the spine that results in the chest protruding posteriorly and the anterior ribs flattening out

35. Bedside Assessment of the Patient • Inspection • Abnormal Chest Configuration Kyphoscoliosis The combination of kyphosis and scoliosis – may produce sever restrictive lung disease as a result of poor lung expansion

36. Bedside Assessment of the Patient • Inspection • Abnormal Chest Configuration Scars • Lobectomy • Pnemonectomy

37. Bedside Assessment of the Patient • Inspection • Abnormal Extremity Findings • Altered Skin Color • Digital Clubbing • Pedal Edema • Distended Neck Veins • Tracheal Deviation

38. Bedside Assessment of the Patient • Inspection • Abnormal Extremity Findings • Altered Skin Color • A general observation of the patient’s skin color should be routinely performed • Does the patient’s skin color look normal? • Is the skin cold or clammy? • Does the skin look ashen or pallid? • Do the patient’s eyes , face, trunk, and arms have a yellow, jaundiced appearance • Is there redness of the skin (erythema)? • Does the patient appear cyanotic?

39. Bedside Assessment of the Patient • Inspection • Abnormal Extremity Findings • Altered Skin Color • Cyanosis – a blue-gray or purplish discoloration of the mucous membranes, fingertips, and toes • Occurs when 5 g/dl of the hemoglobin is reduced (hemoglobin that is not bound with oxygen) Central Cyanosis Observed in the lips and oral mucosa of mouth - almost always a sign of hypoxemia

40. Bedside Assessment of the Patient • Inspection • Abnormal Extremity Findings • Altered Skin Color • Peripheral Cyanosis • Easily seen in the fingernails • Becomes visible when the amount of hemoglobin in the capillary blood exceeds 5-6 g/dL • Mainly the result of poor blood flow, especially in the extremities • Influenced by temperature • Together with coolness of the extremities, peripheral cyanosis is a sign of poor perfusion

41. Bedside Assessment of the Patient • Inspection • Abnormal Extremity Findings • Digital Clubbing • Enlargement of terminal phalanges of the fingers and toes • Significant manifestation of Cardiopulmonary disease • Angle of the fingernail to the nail base increases, nail bed feel “spongy”

42. Bedside Assessment of the Patient • Inspection • Abnormal Extremity Findings • Digital Clubbing • Interstitial lung disease • Bronchiectasis • Various cancers (including lung cancer) • Congenital heart problems that cause cyanosis • Chronic liver disease • Inflammatory bowel disease

43. Bedside Assessment of the Patient • Inspection • Abnormal Extremity Findings • Pedal Edema • Swelling of the lower extremities • Commonly seen in patients with: • Congestive Heart Failure (CHF) • Cor pulmonale (right-sided heart failure) • Liver disease • Kidney disease

44. Bedside Assessment of the Patient • Inspection • Abnormal Extremity Findings • Pedal Edema • Firmly depress the skin for 5 seconds then release • Normal – no indentation • May see some pitting if person has been standing all day or is pregnant • If pitting is present • Subjective scale • 1+ (mild, slight depression) • 4+ (severe, deep depression)

45. Bedside Assessment of the Patient • Inspection • Abnormal Extremity Findings • Capillary Refill • Pressure is applied to the nail bed until it turns white, indicating that the blood has been forced from the tissue (blanching). Once the tissue has blanched, pressure is removed • The health care provider will measure the time it takes for blood to return to the tissue, indicated by a pink color returning to the nail

46. Bedside Assessment of the Patient • Inspection • Abnormal Extremity Findings • Capillary Refill • Caused by reduced cardiac output and poor digital perfusion • Blanch times that are >2 seconds may indicate one of the following: • Dehydration • Shock • Peripheral vascular disease (PVD) • Hypothermia

47. Bedside Assessment of the Patient • Inspection • Abnormal Extremity Findings • Capillary Refill • Normal refill • Infant

48. Bedside Assessment of the Patient • Inspection • Abnormal Extremity Findings • Capillary Refill • Delayed refill • Infant

49. Bedside Assessment of the Patient • Inspection • Abnormal Extremity Findings • Distended Neck Veins • In patients with cor pulmonale, severe flail chest, pneumothorax, or pleural effusion, the major veins of the chest that return blood to the right heart may be compressed. When this happens, venous return decreases and central venous pressure (CVP) increases. This condition is manifested by distended neck veins (also called jugular vein distention – JVD)

50. Bedside Assessment of the Patient • Inspection • Abnormal Extremity Findings • Distended Neck Veins (JVD)