Chapter 16 Egans

Question 1

Bedside Assessment

Answer 1

Process of interviewing and examining a patient for signs and symptoms of disease, as well as evaluating the effects of treatment

Question 2

Diagnosis

Answer 2

Process of identifying the nature and cause of illness

Question 3

Signs

Answer 3

Objective manifestation of illness

Question 4

Symptoms

Answer 4

Subjective experience of some aspects of an illlness

Question 5

Interviewing Purposes

Answer 5

1) Establish rapport between the clinician and patient
2) Obtain info essential for making a diagnosis
3) Help monitor changes in the patients symptoms and response to therapy

Question 6

Intoduction

Answer 6

Social Space: 4-12ft
Personal Space: 2-4ft
Then get level with patient

Question 7

Factors affecting communication

Answer 7

~Sensory/Emotional factors
~Environmental factors
~ Verbal/nonverbal components of the communication process
~Cultural

Question 8

Dyspnea (Difficulty in the mechanical of breathing)

Answer 8

Orthopnea-Dyspnea caused by reclining
~CHF
Platypnea-Dyspnea triggered by assuming upright position
Orthodeoxia-O2 desaturation on assuming an upright position
Trepopnea-Dyspnea from patients with unilateral lung disease lies with the affected side in the dependent position

Question 9

Breathlessness

Answer 9

The unpleasant urge to breathe
~Triggered by acute hypercapnia, acidosis, or hypoxemia

Question 10

4 major areas for interviewing for dyspnea

Answer 10

1) What activities of daily living trigger dyspnea?
2) How much exertion makes the patient stop to catch their breath with different activities?
3) Does the quality of dyspnea vary by the type of activity?
4) When did it first become a common future of your life?

Question 11

Effectiveness of cough depends on

Answer 11

1) Ability to take a deep breath
2) Lung elastic recoil
3) Expiratory muscle strength
4) Level of airway resistance

Question 12

Restrictive lung diseases

Answer 12

CHF, pulmonary fibrosis

Question 13

Sputum Production

Answer 13

Phlegm-Mucus from lungs not contaminated
Sputum-Expectorated from mouth
Purulent-Sputum containing pus
Fetid-Sputum that’s foul smelling

Question 14

Hemoptysis-Coughing up blood

Answer 14

Massive hemoptysis- >300ml in 24 hours
Non-massive hemoptysis- pneumonia, TB, lung cancer, pulmonary embolism

Question 15

Hematemesis

Answer 15

Blood vomited from the gastrointestinal tract that often occurs in patients with gastrointestinal diseases

Question 16

Chest Pain

Answer 16

Pleuritic-Located laterally or posteriorly
Non-Pleuritic- Center of the chest that may radiate
Angina- Non-pleuritic chest pain brought on by exertions or stress and is associated with coronary artery occlusion

Question 17

Pedal Edema- Swelling in lower extremities

Answer 17

Pitting edema- When finger pressure is applied and indention stays
Weeping edema- When applied pressure causes a fluid leak
~ Right-sided/left-sided heart failure

Question 18

Fun Fact

Answer 18

Chronic hypoxemia causes severe pulmonary vasoconstriction and pulmonary hypertension

Question 19

Chief complaint

Answer 19

Detailed, systematic account of the patient’s major complaints written by a physician after the postadmission interview

Question 20

Advance Directive

Answer 20

The patient has formalized his or her wishes for resuscitative efforts

Question 21

Physical Exam

Answer 21

1) Inspection (visually examining)
2) Palpation (touching)
3) Percussion (tapping)
4) Auscultation (listening)

Question 22

Indicators for appearance

Answer 22

1) Level of consciousness
2) Facial expression
3) Level of anxiety or distress
4) positioning

Question 23

Cachexia

Answer 23

Weakness and emaciation

Question 24

Tripod sign

Answer 24

The patient sits upright with elbows on the table that has pulmonary hyperinflation.
~Position gives a mechanical advantage to the accessory breathing muscles of the upper chest and neck

Question 25

Level of consciousness ~Sensorium- used when evaluating a patient's cognitive functioning and level of consciousness

Answer 25

Confused ~Slow mental response Delirious ~ Irritated Lethargic ~ Sleepy, arouses easy Obtunded ~ Awakens only with difficulty ~ Responds appropriately when aroused Stuporous ~ Does not awaken completely Comatose ~Unconscious

Question 26

Vital Signs

Answer 26

Body temp, pulse rate, respiratory rate, blood pressure, pulse oximetry

Question 27

Body Temperature

Answer 27

37 degrees Celsius (98.6 F)

Question 28

Pulse rate

Answer 28

60-100 beats per minute > 100bpm = tachycardia < 60bpm = bradycardia ^~ Difference between both is Pulse Pressure ~Radial artery is the most common site used to palpate the pulse Pulsus Paradoxus- Significant decrease in pulse strength during spontaneous inspiration that can be quantified with a blood pressure cuff Pulsus Alternans- Alternating succession between strong and weak pulses

Question 29

Respiratory rate

Answer 29

12-18 breathe/minute ~ Tachypnea- Rate > 20 breathes ~ Bradypnea- Rate < 10 breathes

Question 30

Arterial Blood Pressure ~ Force exerted by the heart against the systemic arteries as the blood moves through them

Answer 30

Arterial-Peak force exerted in the major arteries during contraction of the left ventricle Diastolic-Force in the major arteries remaining after relaxation of ventricles Hypertension- > 140/90 ~Stage 1: 140-159/ 90-99 ~stage 2: >160/ >100 ~3Rd stage: pre-hypertension 120-139/80-89 Hypotension- ~ Systolic <90 ~ Arterial pressure <65 ~ Decrease in systolic pressure >40 from baseline Shock- inadequate delivery of O2 and nutrients to the vital organs relative to their metabolic demand Postural hypotension- Postural changes in a hypovolemic patient who often produces hypotension Syncope- Fainting

Question 31

Jugular Venous Pressure (JVP)

Answer 31

~Estimated by determining how high the jugular vein extends above the level of the sternal angle Kussmaul sign-When JVP increases during inhalation

Question 32

Jugular Venous Distension (JVD)

Answer 32

Present when the jugular vein is enlarged and can be seen more than 4cm above the sternal angle ~Chronic hypoxemia who develops right heart failure from hypoxemia-induced pulmonary hypertension ~ Left heart failure, Cardiac tamponade, tension pneumothoraxes Lymphadenopathy-Enlarged lymph nodes

Question 33

Barrel chest

Answer 33

Emphysema

Question 34

Abnormalities of thoracic configuration

Answer 34

Pectus carinatum-Abnormal protrusion of the sternum Pectus Excavation- Depression of part or entire sternum Kyphosis- Spine has an abnormal anteroposterior curvature Scoliosis- Spine has a lateral curve Kyphoscoliosis- Combination of both kyphosis and scoliosis

Question 35

Common causes of increased WOB

Answer 35

Airway obstruction, edematous lungs, cardiogenic (stiff chest wall)

Question 36

Respiratory muscles

Answer 36

Can generate inspiratory pressures of 150cm H2O (112mm Hg) Tracheal tugging-Downward movement of the thyroid cartilage toward the chest during inspiration in concert with the sternocleidomastoid muscle recruitment Kussmaul breathing- Rapid/ deep breathing ~Severe metabolic acidosis

Question 37

Abnormal Breathing Patterns

Answer 37

Cheyne Stokes- When RR and Vt gradually increase in intensity and then gradually decrease to complete apnea Agonal breathing- Intermittent prolonged breathing Apnea- No breathing Apneustic breathing- Prolonged inspiratory pause at full inspiration typically lasting for 2-3 seconds Asthmatic breathing- Prolonged exhalation with the recruitment of abdominal muscles Biot respiration- Chaotic breathing pattern characterized by frequent irregularity in both rate and tidal volume that eventually deteriorates to agonal breathing and terminal apnea Central neurogenic hyperventilation- Persistent hyperventilation

Question 38

Paradoxical breathing

Answer 38

~ Abdominal- abdominal wall moves inward on inspiration and outward on expiration ~ Chest- Part or all of the chest wall moves in with inhalation ad out with exhalation

Question 39

Fatigue vs. muscle weakness

Answer 39

~ Inability of contracting muscles to achieve a target pressure ~ Inability to achieve a target pressure in a rested muscle

Question 40

Respiratory Alternans

Answer 40

When the diaphragm and ribcage muscles alternately power breathing in an attempt to rest each muscle group

Question 41

Abdominal Paradox

Answer 41

Complete diaphragmatic fatigue, as the diaphragm is drawn upward into the thoracic cavity with each inspiratory effort of the rib cage muscles

Question 42

Palpation

Answer 42

touching chest wall to evaluate underlying structure and function Vocal Fremitus- Vibrations created by vocal cords from speech Tactile Fremitus- Vibrations felt on the chest wall Subcutaneous Emphysema- Fine air bubbles collecting in subcutaneous tissues produce a crackling sound and sensation when palpated

Question 43

Percussion

Answer 43

Tapping on a surface to evaluate the underlying structure ~Penetrates depth of 5-7cm ~Pneumothorax or lung consolidation Lungs ~Consecutively testing comparable areas on both sides of the chest ~Tympanic- easily heard, moderately low pitched, resonate sound ~Hypertympanic- Louder, deeper, more resonant

Question 44

Resonance

Answer 44

Dull-muffling effects of increased tissue density Hyper-hyperinflation or gas trapped in the pleural place

Question 45

Auscultation

Answer 45

~Listening to bodily sounds 1) Bell 2) Diaphragm 3) Tubing 4) Earpieces

Question 46

Normal breath sounds

Answer 46

Vesicular- Low, Soft, Peripheral lung areas Bronchovesicular- Moderate, Around the upper part of the sternum, between the scapulae Tracheal- High, Loud, Over the trachea

Question 47

Abnormal breath sounds

Answer 47

Adventitious lung sounds- Additional sounds or vibrations produced by air movement through diseased airways Crackles- (discontinuous) crackling or bubbling sounds ~Coarse-excess airway secretions moving throughout the airway ~Severe pneumonia, bronchitis ~Fine-sudden opening of peripheral airways ~Atelectasis, Fibrosis, pulmonary edema Wheezes- (continuous) High or low-pitched quasi-musical sound ~Asthma, congestive heart failure Stridor- (continuous) loud, high-pitched sound associated with upper airway obstruction and often heard without a stethoscope

Question 48

Gallop Rhythm

Answer 48

A patient with heart disease who has S3 and S4

Question 49

Clubbing

Answer 49

Painless enlargement of the terminal phalanges of the fingers and toes associated with numerous cardiopulmonary and other diseases ~COPD

Question 50

Cyanosis

Answer 50

Peripheral- Poor perfusion of the extremities so that tissues extract more O2 Central- Mucosa or the torso are involved and may signal severe lung diseases ~Becomes visible when the amount of unsaturated hemoglobin in capillary blood when exceeds 5-6g/dL

Question 51

Capillary Refill

Answer 51

Pressing firmly on the patient's fingernail until the nail bed is blanched, and then releasing the pressure ~ Normal refill time 3 sec or less ~ Poor output when exceeds 5 sec

Question 52

Types of cough

Answer 52

Acute- Sudden onset, usually severe with a short course Chronic- Persistent, and troublesome for more than 3 weeks Paroxysmal- Periodic, prolonged, and forceful episodes