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1
Bedside Assessment of the
Patient
2
Objectives
• Describe why patient interviews are necessary and
the techniques useful for conducting an interview.
• Identify the abnormalities in lung function
associated with common pulmonary symptoms.
• Identify the breathing patterns associated with
underlying pulmonary pathologic conditions.
3
Objectives (cont.)
• Identify the terms used to describe normal and
abnormal lung sounds.
• Describe the mechanisms responsible for normal
and abnormal lung sounds.
• Describe why it is necessary to examine the
precordium, abdomen, and extremities in the
patient with cardiopulmonary disease and the
common abnormalities seen in these locations.
4
Introduction
• Bedside assessment is the process of interviewing
and examining the patient for the signs and
symptoms of disease.
• It is inexpensive and of little risk to the patient.
• It is done as part of the initial assessment to identify a
diagnosis and in an ongoing manner to evaluate the
effects of treatment.
5
Interviewing
Purposes
• To establish a rapport with patient
• To obtain essential diagnostic information
• To monitor changes in the patient’s symptoms over
time and with treatment
6
Interviewing (cont.)
Technique
• Introduce yourself in the social space.
• Interview in the personal space.
• Use appropriate eye contact.
• Assume a physical position at the same level with the
patient.
• Avoid the use of leading questions; use neutral
questions.
7
Interviewing (cont.)
Common questions to ask for each
symptom
• When did it start?
• How severe is it?
• Where on the body is it?
• What seems to make it better or worse?
• Has it occurred before?
8
Cardiopulmonary Symptoms
Dyspnea
• Occurs when the work of breathing is too high and/or
when the drive to breathe is elevated
• Orthopnea: dyspnea in the reclining position;
associated with CHF
• Platypnea: dyspnea when moved to the upright
position
• Degree of dyspnea is evaluated by asking about the
level of exertion at which it occurs.
9
Cardiopulmonary Symptoms
(cont.)
Cough
• Cough occurs when the cough receptors in the
airways are stimulated by inflammation, mucus,
foreign material, or noxious gases.
• Weak cough is often due to high Raw, poor lung
recoil, or weak muscles.
• Patients with airways disease often have a loose,
productive cough.
10
Cardiopulmonary Symptoms
(cont.)
Sputum production
• Mucus that comes from the lower airways but is
expectorated through the mouth is called “sputum.”
• Sputum that has pus cells in it is said to be “purulent.”
• Sputum that is foul smelling is “fetid.”
• Recent changes in the color, viscosity, or quantity of
sputum may indicate infection.
11
Cardiopulmonary Symptoms
(cont.)
Hemoptysis
 Coughing up blood or bloody sputum from the airways
 Most often occurs in patients with a history of lung
disease
 Common causes include bronchitis, lung cancer,
tuberculosis, trauma, and pulmonary embolism.
 Vomiting blood from the gastrointestinal tract is known
as hematemasis.
12
Cardiopulmonary Symptoms
(cont.)
Chest pain
• Pleuritic chest pain is located laterally or posteriorly,
is sharp in nature, and increases with deep breathing.
• Nonpleuritic chest pain is located in the center of the
chest and may radiate to the shoulder or arm; it is
often caused by coronary artery disease and is
known as angina in such cases.
13
Cardiopulmonary Symptoms
(cont.)
Fever
• Defined as an elevation of body temperature due to
disease
• Most often due to viral infection; also seen with
pneumonia, tuberculosis, and some cancers
• Fever with a cough suggests respiratory infection.
• Fever increases the body’s need for oxygen.
14
Cardiopulmonary Symptoms
(cont.)
Pedal edema
• Swelling of the ankles is most often due to heart
failure.
• Patients with chronic hypoxemic lung disease usually
develop right heart failure (cor pulmonale) due to
pulmonary hypertension.
• Pedal edema may indicate the need for oxygen
therapy.
15
Physical Examination
• Level of consciousness and orientation
to time, place, and person reflect the
oxygenation status of the brain.
• The vital signs (VS) are easy to obtain
and provide useful information about the
current health status of the patient.
• Vital Signs = RR, HR, BT, BP
16
Head and Neck Exam
• Nasal flaring is often seen in infants with respiratory
distress and an increase in the WOB.
• Cyanosis of the oral mucosa indicates respiratory
failure due to low oxygen levels.
• Pursed-lip breathing is seen in patients with COPD
who have obstruction of the small airways.
17
Head and Neck Exam (cont.)
• The trachea should be midline; it may shift left or right
with upper lobe abnormalities or mediastinal tumors.
• Jugular venous distention is seen in patients with
CHF and cor pulmonale.
• Enlarged lymph nodes in the neck may occur with
infection or malignancy.
18
Examination of the Thorax
• A barrel chest is seen with emphysema and indicates
that lung recoil is poor.
19
Examination of the Thorax (cont.)
• Pectus carinatumabnormal protrusion of the
sternum
• Pectus excavatumabnormal depression of the
sternum
• Kyphoscoliosisabnormal curvature of the spine;
often causes severe restrictive lung disease
20
Breathing Pattern
 Rapid and shallow breathing is consistent with
restrictive lung diseases.
 A prolonged expiratory time is consistent with
obstructive lung disease.
 Upper airway obstruction often causes a prolonged
inspiratory time.
 Deep and fast breathing is consistent with Kussmaul
breathing (ketoacidosis).
21
Chest Palpation
• Tactile fremitus is increased with pneumonia and
atelectasis.
• Tactile fremitus in reduced with emphysema,
pneumothorax, and pleural effusion.
• A unilateral reduction in chest expansion is consistent
with pneumonia or pneumothorax.
22
Chest Percussion
• Resonance of the chest is evaluated with percussion.
• The findings should be labeled as “normal, ”
“increased, ” or “decreased” resonance.
• Decreased resonancepneumonia or pleural
effusion.
• Increased resonanceemphysema or
pneumothorax.
23
Chest Auscultation
• Lung sounds come in two varieties: breath sounds
and adventitious lung sounds.
• Breath sounds = the normal sounds of breathing
• ALS = the abnormal sounds superimposed on the
breath sounds (crackles and wheezes)
24
Chest Auscultation (cont.)
Breath sounds
• Tracheal breath sounds: heard directly over the
trachea and created by turbulent flow; loud and high-
pitched
• Bronchovesicular breath soundsheard around the
sternum; softer and slightly lower in pitch
• Vesicular breath soundsheard over lung
parenchyma; represent attenuated turbulent flow
sounds from the larger airways; very soft and low-
pitched
25
Chest Auscultation (cont.)
Breath sounds
 Reduced with shallow breathing and when attenuation
is increased (when the lung is hyperinflated as in
emphysema)
 Increased when attenuation is reduced and the
turbulent flow sounds pass through the lung faster
(pneumonia)
 Increased breath sound are often called “bronchial”
breath sounds.
26
Chest Auscultation (cont.)
ALS
• Come in two varieties: continuous and discontinuous
• Continuous ALS are called “wheezes.”
• A continuous ALS heard over the upper airway is
called “stridor.”
• Discontinuous ALS are called “crackles.”
27
Chest Auscultation (cont.)
• Wheezes are consistent with airways obstruction;
monophonic wheezing indicates one airway is
affected, and polyphonic wheezing indicates many
airways are involved.
• Fine crackles are produced by the sudden opening of
small airways in the lung with deep breathing; they
are heard with pulmonary fibrosis and atelectasis.
28
Chest Auscultation (cont.)
29
Cardiac Examination
• The chest wall overlying the heart is known as the
precordium.
• It is inspected, palpated, and auscultated for
abnormalities.
• Right ventricular hypertrophy causes an abnormal
pulsation that can be seen and felt near the lower
margin of the sternum; this is consistent with cor
pulmonale.
30
Cardiac Examination (cont.)
• A heave is an abnormal pulsation felt over the
precordium.
• A murmur is an abnormal heart sound most often
heard over the precordium.
• Murmurs are produced by blood flowing through a
narrowed opening.
• Systolic murmurs are caused by stenotic semilunar
valves and incompetent AV valves.
31
Cardiac Examination (cont.)
• Diastolic murmurs are caused by stenotic AV valves
or incompetent semilunar valves.
• Murmurs may also be created by rapid blood flow
through a normal valve in healthy people during
heavy exercise.
• Murmurs in babies may suggest cardiovascular
abnormalities related to inadequate adjustment to
extrauterine life.
32
Cardiac Examination (cont.)
 S1 is created by closure of the AV valves.
 S2 is created by closure of the semilunar valves.
 An S3 is abnormal in adults and caused by rapid
filling of a stiff left ventricle.
 An S4 is caused by an atrial “kick” of blood into a
noncompliant left ventricle.
 When a patient has both an S3 and an S4, a gallop
rhythm is present.
33
Abdominal Exam
• The abdomen is inspected and palpated for
distention and tenderness.
• An enlarged liver (hepatomegaly) is consistent with
cor pulmonale.
• Abdominal paradox is present when the abdomen
sinks inward during inspiration; this is a sign of
diaphragm fatigue.
34
Examination of the Extremities
• Digital clubbing is not common but is seen in a large variety of
chronic conditions: congenital heart disease, bronchiectasis,
various cancers, and interstitial lung diseases.
35
Examination of the Extremities
(cont.)
• Digital cyanosis is often a sign of poor perfusion; the
hands and feet are typically cool to the touch in such
cases.

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17 lec PatientBedside Assessment.ppt

  • 2. 2 Objectives • Describe why patient interviews are necessary and the techniques useful for conducting an interview. • Identify the abnormalities in lung function associated with common pulmonary symptoms. • Identify the breathing patterns associated with underlying pulmonary pathologic conditions.
  • 3. 3 Objectives (cont.) • Identify the terms used to describe normal and abnormal lung sounds. • Describe the mechanisms responsible for normal and abnormal lung sounds. • Describe why it is necessary to examine the precordium, abdomen, and extremities in the patient with cardiopulmonary disease and the common abnormalities seen in these locations.
  • 4. 4 Introduction • Bedside assessment is the process of interviewing and examining the patient for the signs and symptoms of disease. • It is inexpensive and of little risk to the patient. • It is done as part of the initial assessment to identify a diagnosis and in an ongoing manner to evaluate the effects of treatment.
  • 5. 5 Interviewing Purposes • To establish a rapport with patient • To obtain essential diagnostic information • To monitor changes in the patient’s symptoms over time and with treatment
  • 6. 6 Interviewing (cont.) Technique • Introduce yourself in the social space. • Interview in the personal space. • Use appropriate eye contact. • Assume a physical position at the same level with the patient. • Avoid the use of leading questions; use neutral questions.
  • 7. 7 Interviewing (cont.) Common questions to ask for each symptom • When did it start? • How severe is it? • Where on the body is it? • What seems to make it better or worse? • Has it occurred before?
  • 8. 8 Cardiopulmonary Symptoms Dyspnea • Occurs when the work of breathing is too high and/or when the drive to breathe is elevated • Orthopnea: dyspnea in the reclining position; associated with CHF • Platypnea: dyspnea when moved to the upright position • Degree of dyspnea is evaluated by asking about the level of exertion at which it occurs.
  • 9. 9 Cardiopulmonary Symptoms (cont.) Cough • Cough occurs when the cough receptors in the airways are stimulated by inflammation, mucus, foreign material, or noxious gases. • Weak cough is often due to high Raw, poor lung recoil, or weak muscles. • Patients with airways disease often have a loose, productive cough.
  • 10. 10 Cardiopulmonary Symptoms (cont.) Sputum production • Mucus that comes from the lower airways but is expectorated through the mouth is called “sputum.” • Sputum that has pus cells in it is said to be “purulent.” • Sputum that is foul smelling is “fetid.” • Recent changes in the color, viscosity, or quantity of sputum may indicate infection.
  • 11. 11 Cardiopulmonary Symptoms (cont.) Hemoptysis  Coughing up blood or bloody sputum from the airways  Most often occurs in patients with a history of lung disease  Common causes include bronchitis, lung cancer, tuberculosis, trauma, and pulmonary embolism.  Vomiting blood from the gastrointestinal tract is known as hematemasis.
  • 12. 12 Cardiopulmonary Symptoms (cont.) Chest pain • Pleuritic chest pain is located laterally or posteriorly, is sharp in nature, and increases with deep breathing. • Nonpleuritic chest pain is located in the center of the chest and may radiate to the shoulder or arm; it is often caused by coronary artery disease and is known as angina in such cases.
  • 13. 13 Cardiopulmonary Symptoms (cont.) Fever • Defined as an elevation of body temperature due to disease • Most often due to viral infection; also seen with pneumonia, tuberculosis, and some cancers • Fever with a cough suggests respiratory infection. • Fever increases the body’s need for oxygen.
  • 14. 14 Cardiopulmonary Symptoms (cont.) Pedal edema • Swelling of the ankles is most often due to heart failure. • Patients with chronic hypoxemic lung disease usually develop right heart failure (cor pulmonale) due to pulmonary hypertension. • Pedal edema may indicate the need for oxygen therapy.
  • 15. 15 Physical Examination • Level of consciousness and orientation to time, place, and person reflect the oxygenation status of the brain. • The vital signs (VS) are easy to obtain and provide useful information about the current health status of the patient. • Vital Signs = RR, HR, BT, BP
  • 16. 16 Head and Neck Exam • Nasal flaring is often seen in infants with respiratory distress and an increase in the WOB. • Cyanosis of the oral mucosa indicates respiratory failure due to low oxygen levels. • Pursed-lip breathing is seen in patients with COPD who have obstruction of the small airways.
  • 17. 17 Head and Neck Exam (cont.) • The trachea should be midline; it may shift left or right with upper lobe abnormalities or mediastinal tumors. • Jugular venous distention is seen in patients with CHF and cor pulmonale. • Enlarged lymph nodes in the neck may occur with infection or malignancy.
  • 18. 18 Examination of the Thorax • A barrel chest is seen with emphysema and indicates that lung recoil is poor.
  • 19. 19 Examination of the Thorax (cont.) • Pectus carinatumabnormal protrusion of the sternum • Pectus excavatumabnormal depression of the sternum • Kyphoscoliosisabnormal curvature of the spine; often causes severe restrictive lung disease
  • 20. 20 Breathing Pattern  Rapid and shallow breathing is consistent with restrictive lung diseases.  A prolonged expiratory time is consistent with obstructive lung disease.  Upper airway obstruction often causes a prolonged inspiratory time.  Deep and fast breathing is consistent with Kussmaul breathing (ketoacidosis).
  • 21. 21 Chest Palpation • Tactile fremitus is increased with pneumonia and atelectasis. • Tactile fremitus in reduced with emphysema, pneumothorax, and pleural effusion. • A unilateral reduction in chest expansion is consistent with pneumonia or pneumothorax.
  • 22. 22 Chest Percussion • Resonance of the chest is evaluated with percussion. • The findings should be labeled as “normal, ” “increased, ” or “decreased” resonance. • Decreased resonancepneumonia or pleural effusion. • Increased resonanceemphysema or pneumothorax.
  • 23. 23 Chest Auscultation • Lung sounds come in two varieties: breath sounds and adventitious lung sounds. • Breath sounds = the normal sounds of breathing • ALS = the abnormal sounds superimposed on the breath sounds (crackles and wheezes)
  • 24. 24 Chest Auscultation (cont.) Breath sounds • Tracheal breath sounds: heard directly over the trachea and created by turbulent flow; loud and high- pitched • Bronchovesicular breath soundsheard around the sternum; softer and slightly lower in pitch • Vesicular breath soundsheard over lung parenchyma; represent attenuated turbulent flow sounds from the larger airways; very soft and low- pitched
  • 25. 25 Chest Auscultation (cont.) Breath sounds  Reduced with shallow breathing and when attenuation is increased (when the lung is hyperinflated as in emphysema)  Increased when attenuation is reduced and the turbulent flow sounds pass through the lung faster (pneumonia)  Increased breath sound are often called “bronchial” breath sounds.
  • 26. 26 Chest Auscultation (cont.) ALS • Come in two varieties: continuous and discontinuous • Continuous ALS are called “wheezes.” • A continuous ALS heard over the upper airway is called “stridor.” • Discontinuous ALS are called “crackles.”
  • 27. 27 Chest Auscultation (cont.) • Wheezes are consistent with airways obstruction; monophonic wheezing indicates one airway is affected, and polyphonic wheezing indicates many airways are involved. • Fine crackles are produced by the sudden opening of small airways in the lung with deep breathing; they are heard with pulmonary fibrosis and atelectasis.
  • 29. 29 Cardiac Examination • The chest wall overlying the heart is known as the precordium. • It is inspected, palpated, and auscultated for abnormalities. • Right ventricular hypertrophy causes an abnormal pulsation that can be seen and felt near the lower margin of the sternum; this is consistent with cor pulmonale.
  • 30. 30 Cardiac Examination (cont.) • A heave is an abnormal pulsation felt over the precordium. • A murmur is an abnormal heart sound most often heard over the precordium. • Murmurs are produced by blood flowing through a narrowed opening. • Systolic murmurs are caused by stenotic semilunar valves and incompetent AV valves.
  • 31. 31 Cardiac Examination (cont.) • Diastolic murmurs are caused by stenotic AV valves or incompetent semilunar valves. • Murmurs may also be created by rapid blood flow through a normal valve in healthy people during heavy exercise. • Murmurs in babies may suggest cardiovascular abnormalities related to inadequate adjustment to extrauterine life.
  • 32. 32 Cardiac Examination (cont.)  S1 is created by closure of the AV valves.  S2 is created by closure of the semilunar valves.  An S3 is abnormal in adults and caused by rapid filling of a stiff left ventricle.  An S4 is caused by an atrial “kick” of blood into a noncompliant left ventricle.  When a patient has both an S3 and an S4, a gallop rhythm is present.
  • 33. 33 Abdominal Exam • The abdomen is inspected and palpated for distention and tenderness. • An enlarged liver (hepatomegaly) is consistent with cor pulmonale. • Abdominal paradox is present when the abdomen sinks inward during inspiration; this is a sign of diaphragm fatigue.
  • 34. 34 Examination of the Extremities • Digital clubbing is not common but is seen in a large variety of chronic conditions: congenital heart disease, bronchiectasis, various cancers, and interstitial lung diseases.
  • 35. 35 Examination of the Extremities (cont.) • Digital cyanosis is often a sign of poor perfusion; the hands and feet are typically cool to the touch in such cases.