This document provides an overview of bedside assessment techniques for evaluating cardiopulmonary patients. It describes how to conduct a patient interview, identify common symptoms, and perform a physical exam of the lungs, heart, abdomen, and extremities. The goals are to establish rapport, obtain diagnostic information, monitor changes over time, and identify abnormalities that may indicate underlying conditions. Proper interviewing, examination of vital signs, breathing patterns, chest auscultation and other physical assessments are described.

1. 1
Bedside Assessment of the
Patient

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.

28. 28
Chest Auscultation (cont.)

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.