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Flashcards in Respiratory Examination Deck (13)
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1

Introduction

- wash hands
- DON PPE (apron - mask - gloves)
-Introduce yourself to the patient (name and status)
- check patients name and DOB (check wristband after)
- ask how patient wants to be addressed (be sure to use this name)
- Explain the examination - consent MUST be verbal (respiratory examination, listen to your chest, tap the chest and look at it).
-Position patient - 45 degrees
- adjust bed height to below your fist
- ask if they have any pain before you begin

2

Initial Assessment

- Stand at the end of the bed
- Do you need to take any rapid intervention?
- Look for patient: Conscious, cyanosis, shortness of breath, using accessory breathing muscles, coughing, looks distressed.
- Look for equipment: Oxygen mask, nebuliser, sputum pot (if there is LOOK INSIDE), prescriptions.
- NEWS chart (STATE SCORE).

3

Hands

LOOK:
- colour (peripheral cyanosis if blue)
- bruising or thinning (long term steroid use, COPD or asthma or interstitial lung disease)
- Finger clubbing: loss of nail bed angle (ask to make diamond shape), increase in longitudinal nail curvature, increased nailed fluctuation, increased bulk of soft tissue over terminal phalanges) (lung cancer, TB, CF, lung abscess)
- koilonychia (iron deficiency anaemia)
- palmar erythema - COPD or smoking

Feel:
- Capillary refill time (press on nail for 5 seconds, should refill after 2-3 seconds) (anaemia)
- temperature - use the back of your hand (both arms to compare) (too hot CO2 retention, too cold cyanosis)

Tremor:
- flapping tremor (cock hands back for 15 seconds) (CO2 retention)
fine tremor (hold hands out straight) (B2 agonists, ie salbutamol)

Pulse:
- use first 2 fingers (take for 15 secs and x4) (60-100 = normal)
- respiratory rate (at the same time as pulse, for 1 minute) (in OSCE, state you will do for 1 minute but might just be asked to move on) (12-20 = normal)
- irregular heart rates should be measured for the full 60 secs for accuracy

Arms:
- check for track marks, scars and bruises

4

Head

- Conjunctiva - white (anaemia), pink (normal)
- tongue and lips (place tongue up to the roof of the mouth) (blue = central cyanosis)
- red face (CO2 retention or COPD)
- horners syndrome signs (pan coast tumour) - ptosis of eyelid - forehead involved, constricted pupil, no sweating

5

Neck

- tracheal position (use one finger and place it on the suprasternal notch, warn them it might be uncomfortable) (mediastinal shift) - away = tension pneumothorax, towards = lobar collapse.
- Cricosternal distance (2-3 finger width in comparison to the patients fingers, should be measured with the fingers face on, not from the side) (descent of trachea = lung hyperinflation = COPD)

6

Lymph nodes

- supraclavicular, anterior cervical chain, pre auricular, post auricular, occipital, tonsil, submandibular, submittal, posterior cervical chain
- should be done with the soft part of the finger, in a massaging motion, continuously.

7

Front of chest

inspection:
- scars (axillary scar - chest drain, median sternotomy scar - CABG, infraclavicular - pacemaker)
- chest wall abnormalities (Pectus excavatum = normal, Pectus carinatum = abnormal pathologies), barrel chest - COPD and asthma.
- skin lesions
- dilated veins

Palpation:
- apex beat (meant to be in 5th intercostal space, mid-clavicular line of LEFT CLAVICLE)
- Chest expansion (in 2 places)

Percussion:
- clavicles, under clavicles, middle and lower chest, mid axillary line.

Auscultation:
- SMALL DIAPHRAGM - for apex (supraclavicular)
- LARGE DIAPHRAGM - for everywhere else
- ^ same areas as percussion
- repeat again with patient saying 'ninety- nine'

8

Back of chest

- ask a patient to hug a pillow (Moves scapula out of the way)

Inspection:
- scars,
- kyphosis (hunchback),
- scoliosis,
- skin lesions,
- dilated veins

Palpation:
- chest expansion - 3 places (upper, middle and lower chest)

Percussion:
- apices, upper, middle, lower, mid-axillary line.

Auscultation:
- make sure to not go over scapula.
- move in triangle shape
- use BIG DIAPHRAGM
- repeat with patient saying 'ninety- nine'

9

End

- thank patient
- make sure bed is lowered so patient can get off
- bed side tests, temperature, peak flow metre etc
- DOFF PPE
- wash hands

10

Extra Notes

- must say your non-findings as well as positive findings
- wash your hands after touching anything that's not the patient
- use the bed adjuster at the bottom of the bed, not next to patient
- always approach right side of bed
- normal temperature = 36.1 - 37.2
- ask what any scars are caused by

11

Percussion Notes

- resonant = normal
- dullness = suggests increased tissue density, normal over heart or liver, not normal if caused by consolidation or tumour etc.
- stony dullness = caused by pleural effusion
- hyper-resonant = decreased tissue density - pneumothorax.

12

Auscultation sounds

- vesicular - normal breath sound at the base - no pause
- tracheal - normal at the top - inspiration and expiration are equal, and there's a pause in between
- bronchiovesicular - normal in the middle

- quiet breath sounds = reduced air entry
- inspiratory stridor = upper airway obstruction
- wheeze = asthma or COPD
- pleural rub = pleurites
- fine crackles = pulmonary fibrosis
- coarse crackles = pneumonia + pulmonary oedema

13

Vocal resonance

- normal
- increased volume- increased tissue density (lobar collapse, consolidation, tumour)
- decreased volume - decreased tissue density (pneumothorax)