Pulmonary Assessment

Question 1

Six Symptoms to be aware of:

Answer 1

1. Cough
2. Sputum
3. Hemoptysis
4. Chest Pain
5. Dyspnea
6. Smoking History

Question 2

Cough should be characterized by…

Answer 2

• time of day
• Productive/Nonproductive
• Related to any exacerbating factor (running in cold weather)

Question 3

Sputum should be described as…

Answer 3

Amount, color, consistency and odor

Ex: 1 cup a day of yellow foul smelling sputum

Question 4

If someone is experiencing hemoptysis while experiencing coughing and vomiting, what must you do?

Answer 4

Distinguish whether it is gastric or cardio/pulmonary

Question 5

When someone is experiencing chest pain, it is characterized into what categories? How do you distinguish if it is cardiac?

Answer 5

Categories: pleuropulmonary (PE, pneuomothorax, pleurisy), cardiovascular or neuromuscular

If you can touch it or manipulate it, it is NOT cardiac.

Question 6

If a patient is experiencing dyspnea, what should you do?

Answer 6

Quantify it. Use clinical reasoning. Use dyspnea scale.

Example:
* A patient who usually runs 5 miles a day who then notices dyspnea after running one mile a day may have new disease.
* A patient who usually can run up two flights of stairs who then notices dyspnea after walking up one flight of stairs may have new disease.

Question 7

How do you document Smoking History?

Answer 7

You want to convert smoking history into “pack-years smoked”
Where 1 pack-year = 20 cigarettes/day for 1 year.

Example: Smoked between the years of 1991 to 1998 & smoked 2 packs per day
[8] x [2] = 16 pack-year

Question 8

When observing a patient what should you look at?

Answer 8

• Clubbing (chronic tissue hypoxia; pulmonary disease)
• Skin (cyanosis; fingers and lips)
• Posture/position (Forward bend - COPD = Professional or Tripod position

Question 9

How does a tripod sitting position help with COPD patients?

Answer 9

Improves length-tension ratio of diaphragm

Allows better use of accessory muscles (pectorals) to elevate anterior chest; Mechanical advantage for ventilation.

Question 10

How long should the respiratory rate be taken?

Answer 10

30 seconds

Question 11

Normal ratio of inspiration to expiration

Answer 11

I:E Ratio can be 1:1-1:2

Expiration is generally longer than inspiration

Question 12

Respiratory Rate Classifications

Answer 12

Normal: 12-20
Tachypnea: increased respiratory rate with shallow breathing pattern >20
Bradypnea: <10

Question 13

Normal Breathing Pattern

Answer 13

Synchronous upward and outward motion of the abdomen and upper chest

Question 14

Abdominal-paradox breathing pattern

Answer 14

Upward and outward motion of the upper-chest and inward motion of the abdomen [hyperinflation of the lungs]

Question 15

Upper chest-paradox breathing pattern

Answer 15

Upward and outward motion of the abdomen and inward motion of the chest [spinal cord injury – have diaphragm but not upper chest innervation]

Question 16

Excessive accessory breathing pattern

Answer 16

Muscle use-Excessive upper-chest motion with increased use of the SCM and scalene muscles. Signifies increased work of breathing and respiratory distress. Dome is compromised, diaphragm is down, the only way now is for muscles.

Question 17

Cheyne-Stokes breathing pattern

Answer 17

A breathing pattern characterized by a period of apnea, followed by gradually increasing depth and frequency of respirations; associated with critically ill patients. Usually happens after something critical. Increase depth and speed to a point then decrease depth and speed, similar to a crescendo and decrescendo.

Question 18

Apnea breathing pattern

Answer 18

A pattern in which there is an absence of breathing.

Question 19

Breathing Patterns and Restrictive lung Disease

Answer 19

Don’t try to change patterns of people with restrictive lung disease as it will not work.

Note breathing patterns as normal and expected or abnormal and unexpected.

Question 20

Tracheal Positioning

Answer 20

Should be in the midline - may deviate contralateral direction due to:

Pneumothorax or ipsilateral direction - negative pressure pulls the trachea towards this side. Will hear no breath sounds if collapsed lung; Emergency situation.

Question 21

What are two types of sternal deformities?

Answer 21

Pectus Carinatum (Pigeon)
Pectus Excavatum (Funnel)

Question 22

What level does the trachea bifuracate?

Answer 22

Lecel of T4 and Sternal Notch

Question 23

What level is the inferior angle of the scapula at?

Answer 23

7th-8th rib/interspace

Question 24

How do you palpate chest wall expansion? What are you looking for?

Answer 24

• Place hands at the base of the rib cage with thumbs equidistant from the xiphoid process or lower ribs.
• Asl patient to take slow, deep breaths and observe for any asymmetric motion of your hands
• Provides information about symmetry of chest movement, Look for asymmetry

Question 25

Types of percussion sounds

Answer 25

Normal Resonance: clear long, low pitches elicited over the normal lung.

Hyperresonance: more vibrant, lower pitched (hollow), louder and longer sound heard normally over the lungs during maximum inspiration
– Possible emphysema or pneumothorax
– Maximally inspire and hold breath - repeat procedure and hold breath

Dullness: short, high pitched, soft and thudding sound that lacks the vibratory quality of a resonant sound. Dullness occurs when the air content of the underlying tissue is decreased and its solidity is increased.
– Possible Pleural Effusion or Lobar Pneumonia

Flatness: very short and flat sound (absolute dullness). For example, sound when tapping over the muscle of the arm or thigh.
– Suggests no air present in the underlying tissue.

Question 26

Diaphragmatic Excursion

Answer 26

The level of excursion should go down 3-8 cm symmetrically.
– Decreased or asymmetrical diaphragmatic excursion may indicate paralysis or emphysema
Diaphram may rise higher on the right due to liver location in some people.

Question 27

How should a patient be instructed to breath when auscultating the lungs?

Answer 27

Breathe with mouth open, a little deeper and faster. Then demonstrate!

Question 28

Decreased breath sounds are when normal lung is displaced by _____ or ____

Answer 28

air (emphysema or pneumothorax) or fluid (pleural effusion)

Question 29

What does a tracheal breath sound like?

Answer 29

loud, harsh, turbulent sound heard over the sternal notch

Question 30

What does Bronchovesicular sound like?

Answer 30

Less harsh, easily, heard sounds of airflow heard in central airways under sternum

Question 31

What does Vesicular sound like? Where do you hear it?

Answer 31

Normal quiet “whishing of airflow through small airways”
– sounds heard over normal lung fields are called vesicular

Question 32

What does Bronchial sound like?

Answer 32

Similar to tracheal breath sounds; but are abnormal when they are heard over the peripheral lung
– Suggest: fluid in the lung (pneumonia)

Question 33

If you hear no movement of air, what does that mean?

Answer 33

absent (no room for air to come into lungs)

Question 34

What is an adventitious sound?

Answer 34

Adventitious sounds are vibrations always resulting from some pathologic process and are not heard over healthy lung tissue. (Are not natural or due to hereditary)

Question 35

What are the two kinds of adventitious sounds?

Answer 35

Crackles: crisp, cracking sounds heard primarily at the base of the lungs. Indicates fibrosis of lung or fluid in alveoli and terminal airways. Occurs during mid to late inspirations. Also known as Rales
Wheezes: Diffused or localized whistling sounds caused by airflow through narrowed distal airways or obstructed larger airways. Rattling, coarse sounds caused by turbulence around mucus in larger airways. Also known as Rhonchi. Continuous sounds either high pitched or low pitched.

Question 36

What does a pleural rub sound like?

Answer 36

Creaking tire swing

Question 37

What is stridor?

Answer 37

Inspiratory wheeze associated with upper airway obstruction. Medical emergency. More common in children (croup). Obstructs air in and out.

Question 38

What is a monophasic wheeze?

Answer 38

Bronchial spasm or mucosal swelling (asthma)

Question 39

What is a polyphonic wheeze?

Answer 39

Expiratory, widespread airflow obstruction (COPD); the collapse of weakened bronchi.