Respiratory assessment Flashcards
Resp Ass - General Appearance
- dyspnoea
- Pt positioning
- pain/discomfort
- evidence of COPD
- cyanosis
- cough
- sputum
- stridor
- dysphonia (hoarseness)
Cough:
- Bovine cough; vocal cord paralysis
- muffled/wheezy/ineffective; suggests obstructive pulmonary Dx
- very loose, productive; excessive bronchial secretions - chronic bronchitis, pneumonia, bronchiectasis
- dry, irritating; chest inf, asthma, CA of bronchus, sometimes LVF or interstitial lung Dx; secondary to ACE inhibitors
- barking/croupy; upper airway problem, pharynx, larynx, or pertussis
Resp Ass - Hands
General
- peripheral cyanosis
- temp
Clubbing
- due to resp Dx in 80% of cases
- does NOT occur due to COPD - other causes; hypertrophic pulmonary osteoarthropathy (lung CAs or pleural fibromas)
Staining
- tar from cigarettes
Wasting & weakness
- wasting of small muscles in hand
- weakness of finger abduction may occurred through compression & infiltration by peripheral lung tumour (T1 nerve root compression)
Pulse
- Rate - tachy, pulses paradoxus in sever asthma
- tachy often accompanies dyspnoea or hypoxia
- full & bounding could indicate CO2 retention
Flapping tremors (asterixis)
- dorsiflexion wrists w arms outstretched & spread fingers
- flapping tremor, w 2-3 sec cycle, may occur w severe CO2 retention
Resp Ass - Face
Face
- red, leathery wrinkled skin (smoking) or other skin changes
Eyes
- inspect for pale conjunctiva (anaemia)
- Horner’s syndrome = constricted pupils, partial ptosis, & loss of sweating = can be due to apical lung tumour (Pancoast’s tumour) compressing sympathetic nerves in the neck
Sinuses
- tenderness over sinuses on palpation = sinusitis
Nose
- polyps (assoc w asthma), engorged turbinates (allergies), or deviated septum
Tongue
- central cyanosis, dehydration
Mouth
- evidence of URTI - reddened pharynx, enlarged tonsils
- broken/rotten teeth - predispose Pt to lung abscess/pneumonia
- crowding of pharynx - space between soft palate, tonsils & back of tongue = sleep apnoea
Resp Ass - Trachea & Chest
Trachea
- position of trachea (slight R sided displacement is normal) significant displacement = Dx of upper lobes
- tracheal tug = gross over-expansion of chest due to obstructive breathing
Chest
- inspect anteriorly & posteriorly; palpate, percuss, & auscultate (comparing side to side)
Chest shapes
Barrel shaped
- anteroposterior diameter > lateral diameter
= severe asthma, emphysema, more normal in elderly
Pigeon chest
- localised prominence & outward bowing of sternum & costal cartilages
= chronic childhood resp illness or Rickets
Funnel chest
- developmental defect involving localised depression of lower end of sternum
= usually aesthetic prob, but can limit lung capacity
Kyphoscoliosis
- may be idiopathic Or 2* to poliomyelitis or Marfan’s syndrome
= reduced lung capacity & inc WOB
Lesions if the chest wall
- scars, operations, chest drains, signs of radiotherapy, sub cut emphysema, prominent veins
Implantable devices
- pacemaker, ICD
Movement
- unilateral - localised lung fibrosis, consolidation, collapse, pleural effusion, pneumothorax
- bilateral - diffuse abnormality eg; COPD, diffuse interstitial lung Dx
- paradoxical inward motion of the abdo - diaphragmatic paralysis
Chest Palpation
General
- tenderness, crepitus, surgical emphysema
- tactile fremitus - palpable vibration caused by spoken word indicates consolidation
Chest expansion
- place hands on Pt’s chest wall (1st anteriorly, 2nd posteriorly) w thumbs meeting in the middle, & fingers extending around the sides of the chest: on deep inspiration, yr thumbs should move symmetrically & apart 5cms
- reduced expansion on one side = lesion or issue on that side
Apex beat
- any displacement should be noted;
- displacement toward lesion: collapse of lower lobe or my localised interstitial lung Dx
- displaced away from lesion: pleural effusion, tension pneumothorax
- impalpable: hyper-expanded chest due to COPD
Ribs
- gentle springing: localised pain suggestive of traumatic or spontaneous rib # (tumour, bone Dx, excessive coughing)
- tenderness over costochondral junctions: costochondritis
Regional lymph nodes
- axillary, supraclavicular, cervical (enlarged due to infection/malignancy)
Chest Percussion
- percuss anterior, posterior & axillary regions
Sounds
- Dull - solid underlying structure, consolidation, collapsed lung
- Extremely Dull - fluid filled area; eg pleural effusion
- Resonant note - Normal lung
- Hyper-resonant - hollow underlying structure like bowel, or pneumothorax
Liver dullness
- upper level of liver dullness is determined by percussing down the R anterior chest in mid-clav line
- Normal 6th intercostal space
- if resonant below this level = hyper-inflation; emphysema/asthma
Cardiac dullness
- usually present on L side of chest; may be decreased in emphysema/asthma
Chest Auscultation
Sounds
- quality
- intensity; normal, reduced
- adventitious sounds; crackles, wheezes, pleural rub
Note:
Early Vs late crackles & density
Pleural rub indicative of pneumonia/pulmonary infarction
Vocal resonance over consolidation?! B’ee’ sounds more like B’a’y
Chest Other
Legs
- oedema, cyanosis, signs of DVT
RR under exertion
- ? Test w mild walking on spot
Temp
- fever indicates acute or chronic infection
Completing the exam:
- cover Pt & assist to redress
- thank Pt
- complete full set of vitals
Further tests?
- peak flow
- spirometry
- sputum specimen
Pulmonary function 2 Dx
Obstructive
- air has trouble flowing out of lungs; COPD, asthma
Restrictive
- chest muscles can’t expand enough; pulmonary fibrosis
Spirometry Assessment Info
- identifies & quantifies defects in airway function
- can measure the severity of obstruction/restriction & then allows for eval of effectiveness of Rxs
FEV: forced expiratory volume; vol of air expired during forced esp approx 1st second
FVC: forced vital capacity; total amount of air expelled during FEV test
VC: gentle expiration
[Note: VC > FVC in COPD]
Testing
- usually best out of 3 is recorded
- then calc FEV1/FVC ratio as a % = normal 70-80% (charts to help)
Low FEV1 w normal ratio = restrictive process
Low FEV1 & decreased ratio = obstructive process
Spirometry Indications
- eval signs, symptoms or abnormal lab results
- measure effects of disease on pulmonary function
- screen Pt’s at risk of Pul Dx
- assess health status before strenuous activity
- assess therapeutic interventions
- document the course of Dx affecting lung function
Spirometry Contraindications
Contraindications
- AMI within the last month
- conditions that lead to suboptimal test;
~ chest, abdo, facial, oral pain
~ stress incontinence
~ dementia/confusion
Cautions:
- spirometry alone may not be sufficient to define; extent of Dx, response to Rx, or level of impairment
- if Pt is compromised, then withhold this test until management completed First
- assess holistically, not just tests in isolation
Notes re test results:
- if Pt coughs, test is void
- recent meds affect results
- 3 attempts within 5% are req for it to be valid
- dizziness, SOB, coughing have all been reported side effects & can also precipitate an asthma episode
Aortic Stenosis
[S1, EC; crescendo-decrescendo murmur, S2]
EC - heard best over Apex
*systolic ejection murmur - sound between S1 & S2
{Pulmonic stenosis; similar sound but heard over Pulmonic area & nil radiation to neck!}
Mitral Regurgitation
[S1:murmur:S2]
- heard over Apex/mitral area
- flat murmur, no change in volume/intensity
{Tricuspid regurgitation: same but heard over tricuspid area, does not radiate to Apex}
