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

RET 1024RET 1024Introduction to Respiratory Introduction to Respiratory TherapyTherapy

Module 4.2Module 4.2

Bedside Assessment of the PatientBedside Assessment of the Patient― InspectionInspection

Bedside Assessment of the PatientBedside Assessment of the Patient

Systematic Examination Thorax and LungsSystematic Examination Thorax and Lungs The physical examination of the chest and lungs should The physical examination of the chest and lungs should

be performed in a systematic and orderly fashion – the be performed in a systematic and orderly fashion – the most common sequence is as follows:most common sequence is as follows:

InspectionInspection

Palpation Palpation

PercussionPercussion

AuscultationAuscultation


Systematic Examination Thorax and LungsSystematic Examination Thorax and Lungs Topographic landmarks of the lung and chestTopographic landmarks of the lung and chest











Left lower lobe

Left oblique fissure

Left upper lobe




InspectionInspection DyspneaDyspnea Abnormal ventilatory patternAbnormal ventilatory pattern Use of accessory muscles of inspirationUse of accessory muscles of inspiration Pursed-lip breathingPursed-lip breathing Substernal or intercostal retractionsSubsternal or intercostal retractions Nasal flaringNasal flaring Splinting due to chest painSplinting due to chest pain


InspectionInspection Abnormal extremity findings:Abnormal extremity findings:

Altered skin colorAltered skin color Digital clubbingDigital clubbing Pedal edemaPedal edema Capillary refill Capillary refill Distended neck veinsDistended neck veins Tracheal deviationTracheal deviation

Cough (note characteristics)Cough (note characteristics) Sputum productionSputum production HemoptysisHemoptysis


Dyspnea; shortness of breath as defined Dyspnea; shortness of breath as defined by the patientby the patient Patient’s sense that their work of breathing is Patient’s sense that their work of breathing is

excessive for their level of activityexcessive for their level of activity

Shortness of breath becomes a concern when Shortness of breath becomes a concern when the the drivedrive to breathe to breathe is excessive or when the is excessive or when the work of breathingwork of breathing increases increases


DyspneaDyspnea Drive to breatheDrive to breathe is excessive is excessive

HypoxemiaHypoxemia AcidosisAcidosis FeverFever ExerciseExercise AnxietyAnxiety


DyspneaDyspnea Increased work of breathingIncreased work of breathing

Narrowed airways, e.g., Narrowed airways, e.g., AsthmaAsthma BronchitisBronchitis

Lung become difficult to expand, e.g., Lung become difficult to expand, e.g., PneumoniaPneumonia Pulmonary edemaPulmonary edema Chest wall abnormalityChest wall abnormality


DyspneaDyspnea PositionalPositional

Reclining – OrthopneaReclining – Orthopnea CHFCHF Bilateral diaphragmatic paralysisBilateral diaphragmatic paralysis

Upright - PlatypneaUpright - Platypnea


DyspneaDyspnea Patient’s description of their dyspneaPatient’s description of their dyspnea

““My chest is tight”My chest is tight”

““My breathing is too fast”My breathing is too fast”

““I feel like I’m suffocating”I feel like I’m suffocating”


InspectionInspection Abnormal Ventilatory Pattern Abnormal Ventilatory Pattern

Provide reliable clues about underlying pulmonary Provide reliable clues about underlying pulmonary problemproblem

Rapid shallow breathing (Rapid shallow breathing (Rate with a Rate with a VVT T ))

Caused by Caused by lung volume and/or lung volume and/or lung compliance (C lung compliance (CLL)) AtelectasisAtelectasis PneumoniaPneumonia Pulmonary edemaPulmonary edema Pleural effusionPleural effusion PneumothoraxPneumothorax Adult respiratory distress syndrome (ARDS)Adult respiratory distress syndrome (ARDS)



Prolonged Prolonged exhalationexhalation time ( time ( Rate with a Rate with a V VT T ))

Caused by Caused by airway resistance (R airway resistance (Rawaw))

Cystic fibrosisCystic fibrosis BrochiectasisBrochiectasis AsthmaAsthma BronchitisBronchitis EmphysemaEmphysema



Prolonged Prolonged inspiratoryinspiratory time time Upper airway obstruction – extrathoracicUpper airway obstruction – extrathoracic

EpiglotitisEpiglotitis CroupCroup Extrathoracic tumorExtrathoracic tumor


InspectionInspection Use of accessory musclesUse of accessory muscles

During the advanced stages of chronic obstructive During the advanced stages of chronic obstructive pulmonary disease (COPD), the accessory muscles of pulmonary disease (COPD), the accessory muscles of inspiration are activated when the diaphragm becomes inspiration are activated when the diaphragm becomes significantly depressed by the increased residual significantly depressed by the increased residual volume (RV) and functional residual capacity (FRC)volume (RV) and functional residual capacity (FRC)

Accessory muscles of inspirationAccessory muscles of inspiration ScaleneScalene SternocleidomastoidSternocleidomastoid Pectoralis majorPectoralis major TrapeziusTrapezius



Accessory muscles of expiration Accessory muscles of expiration Recruited when airway resistance becomes Recruited when airway resistance becomes

significantly elevatedsignificantly elevated Rectus abdominisRectus abdominis External obliquesExternal obliques Internal obliquesInternal obliques Transversus abdominisTransversus abdominis




InspectionInspection Pursed-lip BreathingPursed-lip Breathing

Occurs in patients during the Occurs in patients during the advanced stages of obstructive advanced stages of obstructive pulmonary diseasepulmonary disease

Patient exhales through lips that Patient exhales through lips that are held in position similar to that are held in position similar to that used for whistling or blowing trough used for whistling or blowing trough a flutea flute

Retarding the airflow through the Retarding the airflow through the pursed lips provides the airway with pursed lips provides the airway with some stability - offsets early airway some stability - offsets early airway collapsecollapse


InspectionInspection Pursed-lip BreathingPursed-lip Breathing


InspectionInspection RetractionsRetractions

Caused by a greater than normal negative intrapleural Caused by a greater than normal negative intrapleural pressure during inspiratory efforts to overcome low pressure during inspiratory efforts to overcome low lung compliance as seen in patients with severe lung compliance as seen in patients with severe restrictive lung disorders, e.g., pneumonia, ARDS, and restrictive lung disorders, e.g., pneumonia, ARDS, and in premature newborns with surfactant deficiencies or in premature newborns with surfactant deficiencies or idiopathic respiratory distress (IRDS)idiopathic respiratory distress (IRDS) SternalSternal IntercostalIntercostal SupraclavicularSupraclavicular SubcostalSubcostal


InspectionInspection RetractionsRetractions

Sternal retractions

Intercostal retractions

Supraclavicular retractions

Subcostal retractions


InspectionInspection Nasal FlaringNasal Flaring

Often seen during Often seen during inspiration in infants inspiration in infants experiencing experiencing respiratory distressrespiratory distress

Provides a larger Provides a larger orifice for gas to orifice for gas to enter the lungs enter the lungs during inspirationduring inspiration


InspectionInspection Splinting Due to Chest PainSplinting Due to Chest Pain

Pleuritic Chest PainPleuritic Chest Pain Sudden sharp, stabbing type pain located laterally Sudden sharp, stabbing type pain located laterally

or posteriorlyor posteriorly Worsens with deep breathWorsens with deep breath Origin may be from:Origin may be from:

Chest wallChest wall MusclesMuscles RibsRibs DiaphragmDiaphragm Mediastinal structuresMediastinal structures Intercostal nervesIntercostal nerves Parietal pleura (pleurisy)Parietal pleura (pleurisy)



Pleuritic Chest PainPleuritic Chest Pain A characteristic feature of the following respiratory A characteristic feature of the following respiratory

diseases:diseases: PneumoniaPneumonia Pleural effusionPleural effusion PneumothoraxPneumothorax Pulmonary infarctionPulmonary infarction Lung cancerLung cancer PneumoconiosisPneumoconiosis Fungal diseasesFungal diseases TBTB



Nonpleuritic Chest PainNonpleuritic Chest Pain Described as constant “dull ache” or “pressure” Described as constant “dull ache” or “pressure”

located in the center of the anterior chest, may located in the center of the anterior chest, may radiate to the shoulderradiate to the shoulder

Associated with the following disorders:Associated with the following disorders: Myocardial ischemiaMyocardial ischemia Pericardial inflammationPericardial inflammation Pulmonary hypertensionPulmonary hypertension EsophagitisEsophagitis Local trauma or inflammation of the chest cage, Local trauma or inflammation of the chest cage,

muscles, bones, or cartilagemuscles, bones, or cartilage


InspectionInspection Abnormal Chest ConfigurationAbnormal Chest Configuration

During inspection the respiratory care practitioner During inspection the respiratory care practitioner systematically observes the patient’s chest for both systematically observes the patient’s chest for both normal and abnormal findingsnormal and abnormal findings

Is the spine straight?Is the spine straight? Are any lesions or surgical scars evident?Are any lesions or surgical scars evident? Are the scapulae symmetric?Are the scapulae symmetric?



Anteroposterior (AP) diameterAnteroposterior (AP) diameter Slightly with age and prematurely with COPDSlightly 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



Pectus carinatum

– forward projection of the xiphoid process and lower sternum (aka: “pigeon breast”

Pectus excavatum

– funnel-shaped depression over the lower sternum (aka: “funnel chest”) -associated with restrictive lung defects



ScoliosisKyphosis

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



Kyphoscoliosis

The combination of kyphosis and scoliosis – may produce sever restrictive lung disease as a result of poor lung expansion



Scars•Lobectomy•Pnemonectomy


InspectionInspection Abnormal Extremity FindingsAbnormal Extremity Findings

Altered Skin ColorAltered Skin Color

Digital ClubbingDigital Clubbing

Pedal EdemaPedal Edema

Distended Neck VeinsDistended Neck Veins

Tracheal DeviationTracheal Deviation



Altered Skin ColorAltered Skin Color A general observation of the patient’s skin color should A general observation of the patient’s skin color should

be routinely performedbe routinely performed Does the patient’s skin color look normal?Does the patient’s skin color look normal? Is the skin cold or clammy?Is the skin cold or clammy? Does the skin look ashen or pallid?Does the skin look ashen or pallid? Do the patient’s eyes , face, trunk, and arms have a Do the patient’s eyes , face, trunk, and arms have a

yellow, jaundiced appearanceyellow, jaundiced appearance Is there redness of the skin (erythema)?Is there redness of the skin (erythema)? Does the patient appear cyanotic?Does the patient appear cyanotic?



Altered Skin ColorAltered Skin Color Cyanosis – a blue-gray or purplish discoloration of the Cyanosis – a blue-gray or purplish discoloration of the

mucous membranes, fingertips, and toesmucous membranes, fingertips, and toes Occurs when 5 g/dl of the hemoglobin is reduced Occurs when 5 g/dl of the hemoglobin is reduced

(hemoglobin that is not bound with oxygen)(hemoglobin that is not bound with oxygen)

Observed in the lips and oral mucosa of mouth - almost always a sign of hypoxemia

Central Cyanosis



Altered Skin ColorAltered Skin Color Peripheral CyanosisPeripheral Cyanosis

Easily seen in the fingernailsEasily seen in the fingernails Becomes visible when the amount of hemoglobin in Becomes visible when the amount of hemoglobin in

the capillary blood exceeds 5-6 g/dLthe capillary blood exceeds 5-6 g/dL Mainly the result of poor blood flow, especially in the Mainly the result of poor blood flow, especially in the

extremitiesextremities Influenced by temperatureInfluenced by temperature Together with coolness of the extremities, peripheral Together with coolness of the extremities, peripheral

cyanosis is a sign of poor perfusioncyanosis is a sign of poor perfusion



Digital ClubbingDigital Clubbing Enlargement of terminal Enlargement of terminal

phalanges of the fingers and toesphalanges of the fingers and toes Significant manifestation of Significant manifestation of

Cardiopulmonary diseaseCardiopulmonary disease Angle of the fingernail to the nail Angle of the fingernail to the nail

base increases, nail bed feel base increases, nail bed feel “spongy”“spongy”



Digital ClubbingDigital Clubbing Interstitial lung diseaseInterstitial lung disease BronchiectasisBronchiectasis Various cancers (including lung Various cancers (including lung

cancer)cancer) Congenital heart problems that Congenital heart problems that

cause cyanosiscause cyanosis Chronic liver diseaseChronic liver disease Inflammatory bowel diseaseInflammatory bowel disease



Pedal EdemaPedal Edema Swelling of the lower extremitiesSwelling of the lower extremities Commonly seen in patients with:Commonly seen in patients with:

Congestive Heart Failure (CHF)Congestive Heart Failure (CHF) Cor pulmonale (right-sided heart failure)Cor pulmonale (right-sided heart failure) Liver diseaseLiver disease Kidney diseaseKidney disease



Pedal EdemaPedal Edema Firmly depress the skin for 5 Firmly depress the skin for 5

seconds then releaseseconds then release Normal – no indentationNormal – no indentation May see some pitting if person May see some pitting if person

has been standing all day or is has been standing all day or is pregnantpregnant

If pitting is presentIf pitting is present Subjective scaleSubjective scale

1+ (mild, slight depression)1+ (mild, slight depression) 4+ (severe, deep 4+ (severe, deep

depression)depression)



Capillary RefillCapillary Refill Pressure is applied to the nail Pressure is applied to the nail

bed until it turns white, bed until it turns white, indicating that the blood has indicating that the blood has been forced from the tissue been forced from the tissue (blanching). Once the tissue has (blanching). Once the tissue has blanched, pressure is removedblanched, pressure is removed

The health care provider will The health care provider will measure the time it takes for measure the time it takes for blood to return to the tissue, blood to return to the tissue, indicated by a pink color indicated by a pink color returning to the nailreturning to the nail



Capillary RefillCapillary Refill Caused by reduced cardiac output Caused by reduced cardiac output

and poor digital perfusionand poor digital perfusion Blanch times that are >2 seconds Blanch times that are >2 seconds

may indicate one of the following:may indicate one of the following: DehydrationDehydration ShockShock Peripheral vascular disease Peripheral vascular disease

(PVD)(PVD) HypothermiaHypothermia



Capillary RefillCapillary Refill

Normal refillNormal refill InfantInfant



Capillary RefillCapillary Refill

Delayed refillDelayed refill InfantInfant



Distended Neck VeinsDistended Neck Veins In patients with cor pulmonale, severe flail chest, In patients with cor pulmonale, severe flail chest,

pneumothorax, or pleural effusion, the major veins pneumothorax, or pleural effusion, the major veins of the chest that return blood to the right heart may of the chest that return blood to the right heart may be compressed. When this happens, venous be compressed. When this happens, venous return decreases and central venous pressure return decreases and central venous pressure (CVP) increases. This condition is manifested by (CVP) increases. This condition is manifested by distended neck veins (also called jugular vein distended neck veins (also called jugular vein distention – JVD)distention – JVD)



Distended Neck Veins (JVD)Distended Neck Veins (JVD)



Distended Neck Veins (JVD)Distended Neck Veins (JVD) Elevate head of patient’s Elevate head of patient’s

bed to 45bed to 45 Blood column should only Blood column should only

be a few centimeters above be a few centimeters above the clavicle the clavicle

If venous pressure is If venous pressure is elevated, neck veins may elevated, neck veins may be distended as far as the be distended as far as the jawjaw



Tracheal DeviationTracheal Deviation Trachea normally in middle of neckTrachea normally in middle of neck

Directly below the center of the suprasternal notchDirectly below the center of the suprasternal notch Shifts towardShifts toward

Collapsed lungCollapsed lung AtelectasisAtelectasis PneumonectomyPneumonectomy

Shifts awayShifts away Increased air (tension pneumothorax)Increased air (tension pneumothorax) Increased fluid (pleural effusionIncreased fluid (pleural effusion Increased tissue (tumor)Increased tissue (tumor)


Tracheal DeviationTracheal Deviation Tracheal shiftTracheal shift

PneumonectoryPneumonectory


Tracheal DeviationTracheal Deviation Tracheal shiftTracheal shift

Pleural effusionPleural effusion


InspectionInspection CoughCough

Most common symptom in patients with Most common symptom in patients with pulmonary diseasepulmonary disease

Occurs when cough receptors are stimulatedOccurs when cough receptors are stimulated InflammationInflammation MucusMucus Foreign materialsForeign materials Noxious gasesNoxious gases


InspectionInspection CoughCough

CharacteristicsCharacteristics Dry or looseDry or loose Productive or nonproductiveProductive or nonproductive Acute or chronicAcute or chronic During day or nightDuring day or night


Dry, loose, productive … ?Dry, loose, productive … ?


InspectionInspection Sputum ProductionSputum Production

Airway disease may cause mucus productionAirway disease may cause mucus production

Phlegm – Phlegm – mucus from the tracheobronchial tree, mucus from the tracheobronchial tree, notnot contaminated by oral secretionscontaminated by oral secretions

SputumSputum – mucus from the lung but passes through – mucus from the lung but passes through the mouththe mouth



Terminology associated the sputumTerminology associated the sputum

Purulent – Purulent – sputum that contains pus (bacterial sputum that contains pus (bacterial infection – thick, colored, sticky)infection – thick, colored, sticky)

Fetid – foul smelling sputumFetid – foul smelling sputum

Mucoid – clear, thick sputumMucoid – clear, thick sputum



Recent changes in the Recent changes in the color, viscosity, or color, viscosity, or quantity or sputum quantity or sputum produced are often produced are often signs of infection and signs of infection and must be documented must be documented and reported to the and reported to the physicianphysician


InspectionInspection Hemoptysis; coughing up blood or blood-streaked Hemoptysis; coughing up blood or blood-streaked

sputum from the lungssputum from the lungs Massive - > 300 ml over 24 hoursMassive - > 300 ml over 24 hours

BronchiectasisBronchiectasis Lung abscessLung abscess Acute or old tuberculosisAcute or old tuberculosis

Nonmassive - < 300 ml over 24 hoursNonmassive - < 300 ml over 24 hours Infection of airwaysInfection of airways Lung cancerLung cancer TuberculosisTuberculosis TraumaTrauma Pulmonary embolismPulmonary embolism

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

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