1. Respiratory Care Board
2. Clinical Assessment In Respiratory Care

Inflammatory Infection, lung abscess, drug reaction, allergy, edema, hyperemia, collagen-vascular disease, radiotherapy, pneumoconiosis, tuberculosis Mechanical Inhaled dusts, suction catheter, food, etc. Obstructive Foreign bodies, aspirations of nasal secretions, tumor or granulomas within or around the lung, aortic aneurysm Airway wall tension Pulmonary edema, atelectasis, fibrosis, chronic interstitial pneumonitis Chemical Inhaled irritant gases, fumes, smoke Temperature Inhaled hot or cold air Ear Tactile pressure in the ear canal (Arnold's nerve response) or from otitis media (al 29) al, Wilkins et. Clinical Assessment in Respiratory Care, 6th Edition.

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Mosby, 022009. Hemoptysis History-Cardiopulmonary disease Patient says- Coughed up from lungs/chest Associated symptoms- Dyspnea, pain or tickling sensation in chest Blood: pH-Alkaline Mixed with-Sputum Froth-May be present Color-Bright red Hematemesis History-Gastrointestinal disease Patient says-Vomited from stomach Associated symptoms- Nausea, pain referred to stomach Blood: pH-Acid Mixed with-Food Froth-Absent Color-Dark, clotted, 'coffee grounds' (al 33) al, Wilkins et. Clinical Assessment in Respiratory Care, 6th Edition. Mosby, 022009. Paroxysmal Nocturnal Dyspnea.Sudden onset of dyspnea while lying flat.CHF.Usually occurs within 1-2 hours of lying down Orthopnea.Inability to breath while lying down Patient need to have several pillows when in recumbent position.Left heart failure Treopnea.Dyspnea while lying on one side.Pleural effusion Platypnea.Dyspnea in an upright position and usually needs to lay flat-heart problem Orthodeoxia.Decrease oxygen saturation in upright position.Relieved by recumbent position.Heart disease. Chest wall pain is well-localized, constant.

Chest pain caused by pulmonary disease is usually the result of involvement of the chest wall or parietal pleura (the serous membrane that lines the inner chest wall), both of which are well supplied with pain fibers. Chest wall pain may originate from the intercostal and pectoral muscles, ribs, and cartilages, or stimulation of a neural pathway (neuralgia) anywhere along a dermatome (skin area innervated by a particular spinal cord segment). It is usually described as a well-localized, constant aching soreness that increases with direct pressure on the area of tenderness and with any arm movement that stretches the thoracic muscles.

(al 41) al, Wilkins et. Clinical Assessment in Respiratory Care, 6th Edition. Mosby, 022009. Pleuritic pain is sharp, during inspiration, abrupt in onset. Pleuritic pain, often described as inspiratory pain, is the most common symptom of disease causing inflammation of the pleura (pleurisy). It is sharp, often abrupt in onset, and severe enough to cause the patient to seek medical help (often within hours of onset). It increases with inspiration, a cough, a sneeze, a hiccup, or laughing.

Pleuritic pain is usually localized to one side of the chest, frequently the lower, lateral aspect. It may be only partially relieved by splinting and pain medication. Pleuritic pain increases with pressure and movement but not to the same degree as pain originating from the outer chest wall. In contrast, the lung parenchyma and the visceral pleura that cover the lungs are relatively insensitive to pain; therefore pain with breathing usually indicates involvement of the parietal pleura.

(al 41-42) al, Wilkins et. Clinical Assessment in Respiratory Care, 6th Edition.

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Mosby, 022009. Syncope is a temporary loss of consciousness caused by reduced blood flow and therefore a reduced supply of oxygen and nutrients to the brain. Reduced cerebral blood flow may be localized (as in cerebral thrombosis, embolism, or atherosclerotic obstruction) or generalized as occurs with obstruction to blood flow from the heart, cardiac arrhythmias, and hypovolemia (decreased available blood volume). (al 42) al, Wilkins et.

Clinical Assessment in Respiratory Care, 6th Edition. Mosby, 022009. Edema is soft tissue swelling resulting from an abnormal accumulation of fluid. It may be generalized (anasarca), may appear only in dependent body areas (feet and ankles in ambulatory patients or the sacral area in patients on bed rest), or may be limited to a single extremity or organ (such as pulmonary edema). Edema is associated with kidney disease, liver disease, cardiac and pulmonary disease, and obstruction of venous or lymphatic drainage of an extremity.

Patients may report that when they press on their swollen ankles or when they remove their shoes and socks, they notice a depression that remains in place for at least several minutes. When compression of an edematous area produces a depression that does not fill immediately, pitting edema is present.

In the medical history, pitting edema is usually described in general terms such as 'the patient denies pitting edema' or 'the patient reports pitting edema in both ankles that remains for at least 5 minutes after leg elevation.' (al 44) al, Wilkins et. Clinical Assessment in Respiratory Care, 6th Edition. Mosby, 022009. Enlargement of the heart's right ventricle caused by primary lung disease.

In some patients, the left ventricle also increases in size. Cor pulmonale eventually results in failure of the right ventricle, which cannot accommodate an increase in pressure as easily as the left ventricle. Pulmonary hypertension associated with this condition is caused by some disorder of the pulmonary parenchyma or of the pulmonary vascular system between the origin of the left pulmonary artery and the entry of the pulmonary veins into the left atrium. ( Mosby 461) Mosby. Mosby's Dictionary of Medicine, Nursing & Health Professions, 8th Edition.

Mosby, 122008. Peripheral (dependent) edema caused by pulmonary diseases occurs when the disease process causes narrowing of the capillaries in the lung, requiring the right ventricle to generate higher and higher pressures to move blood through the lungs. Gradually, the overworked right ventricle becomes enlarged and unable to pump all of its blood through the lungs. As right heart failure worsens, dependent edema is no longer relieved by rest or changing position and the edema occurs in the abdominal organs, as well as the extremities and dependent areas of the body. As the liver becomes enlarged (hepatomegaly) because of the edema, the patient may also complain of pain just below the ribs on the right side (right upper quadrant pain).

(al 44) al, Wilkins et. Clinical Assessment in Respiratory Care, 6th Edition.

Mosby, 022009. Cause SOB Type of Dyspnea: Chronic dyspnea with gradual onset, PND Associated symptoms: Edema, dyspnea remains long after exercise is stopped Precipitating and aggravating factors: exercise, recumbency, trauma, anesthesia, shock, hemorrhage, calcium channel blockers or beta blockers Patient characteristics: older patients, nocturnal dyspnea relieved by sitting Usual physical findings: Shallow respirations but not necessarily rapid, basilar crackles, jugular venous distention, edema, third heart sound, heptomegaly. Normally, the trachea is located centrally in the neck when the patient is facing forward. The midline of the neck can be identified by palpation of the suprasternal notch at the base of the anterior neck.

The midline of the trachea should be directly below the center of the suprasternal notch. The trachea may be shifted from midline with unilateral upper lobe collapse (atelectasis), pneumothorax, pleural effusion, or lung tumors.

The trachea shifts toward the collapsed lung but away from the pneumothorax, pleural effusion, or lung tumor. Abnormalities in the lower lung fields may not shift the trachea unless the defect is severe. (al 71) al, Wilkins et.

Clinical Assessment in Respiratory Care, 6th Edition. Mosby, 022009. JVP: level of column of blood in JV reflects V and P of venous blood in the R side of the heart. In supine position: JVs are full. With 45º angle, column of blood descends to few cm above clavicle. Normal: 3-4 cm High venous P: column remains high even when pt is sitting upright.

Measure distance veins are distended above sternal angle (5cm above R atrium). In supine position: JVs are full. With 45º angle, column of blood descends to few cm above clavicle. Normal: 3-4 cm Measure distance veins are distended above sternal angle (5cm above R atrium). JVP changes with breathing. Most common cause of JVD is right heart failure (RHF). RHF occurs from chronic left-sided heart failure or when chronic hypoxemic lung disease is present (cor pulmonale).

Other causes of JVD: Hypervolemia. Obstruction of venous return to R atrium. Drivewindow light. Enlargement of the heart's right ventricle caused by primary lung disease.

In some patients, the left ventricle also increases in size. Cor pulmonale eventually results in failure of the right ventricle, which cannot accommodate an increase in pressure as easily as the left ventricle. Pulmonary hypertension associated with this condition is caused by some disorder of the pulmonary parenchyma or of the pulmonary vascular system between the origin of the left pulmonary artery and the entry of the pulmonary veins into the left atrium. ( Mosby 461) Mosby. Mosby's Dictionary of Medicine, Nursing & Health Professions, 8th Edition. Mosby, 122008. Pedal edema may occur in patients with chronic lung disease that has resulted in cor pulmonale or chronic right-sided heart failure.

(al 91) al, Wilkins et. Clinical Assessment in Respiratory Care, 6th Edition. Mosby, 022009.

Imaginary Lines On the anterior chest, the midsternal line divides the chest into two equal halves. The left and right midclavicular lines parallel the midsternal line and are drawn through the midpoints of the left and right clavicles, respectively (Figure 5-3).

The midaxillary line divides the lateral chest into two equal halves. The anterior axillary line parallels the midaxillary line and is situated along the anterolateral chest. The posterior axillary line is also parallel to the midaxillary line and is located in the posterolateral chest (Figure 5-4).

Three imaginary vertical lines are drawn on the posterior chest. The midspinal line divides the posterior chest into two equal halves. The left and right midscapular lines parallel the midspinal line and pass through the inferior angles of the scapulae in the relaxed upright patient (Figure 5-5).

(al 73) al, Wilkins et. Clinical Assessment in Respiratory Care, 6th Edition. Mosby, 022009. See pics on slides and chapter 5 Clinical assesment textbook. A.Tracheal Bifurcation On the anterior chest, the carina is located approximately beneath the sternal angle and on the posterior chest at approximately T4.

B.The diaphragm is a dome-shaped muscle that lies between the thoracic and abdominal cavities and moves up and down during normal ventilation. At the end of a tidal expiration, the right dome of the diaphragm is located at the level of T9 posteriorly and the fifth rib anteriorly. On the left, the diaphragm comes to rest at the end of expiration at T10 posteriorly and the sixth rib anteriorly. C.Borders of the anterior and posterior lungs The inferior borders on the anterior chest extend to approximately the sixth rib at the midclavicular line and to the eighth rib on the lateral chest wall. On the posterior chest, the superior border extends to T1, and the inferior border varies with ventilation between approximately T9 and T12 d. Mediastinum a part of the thoracic cavity in the middle of the thorax, between the pleural sacs containing the two lungs. It extends from the sternum to the vertebral column and contains all the thoracic viscera except the lungs.

It is enclosed in a thick extension of the thoracic subserous fascia and is divided into the anterior mediastinum, middle mediastinum, posterior mediastinum, and superior mediastinum e. Hilum an area of the lung where the mediastinal pleura is continuous with the visceral pleura. Pectus carinatum: Sternal protrusion anteriorly. Pectus excavatum: Depression of part or all of the sternum, which can produce a restrictive lung defect. Kyphosis: Spinal deformity in which the spine has an abnormal anteroposterior curvature (Figure 5-11). Scoliosis: Spinal deformity in which the spine has a lateral curvature (see Figure 5-11). Kyphoscoliosis: Combination of kyphosis and scoliosis; may produce a severe restrictive lung defect as a result of poor lung expansion (see Figure 5-11).

Severe trauma to the chest cage can result in fractures of the ribs and sternum. Abnormal configuration of the thoracic cage may result, especially if multiple ribs are broken. A section of the rib cage may move paradoxically with breathing when multiple ribs are fractured at more than one site. The paradoxical motion is seen as a sinking inward of the affected region with each spontaneous inspiratory effort and an outward movement with subsequent exhalation.

This paradoxical motion of the affected rib cage is called flail chest. (al 75-76) al, Wilkins et. Clinical Assessment in Respiratory Care, 6th Edition. Mosby, 022009. The patient should be sitting upright in a relaxed position when possible. The patient is instructed to breathe a little deeper than normal with the mouth open.

Inhalation should be an active process and exhalation passive. The bell or diaphragm is placed directly against the chest wall to eliminate clothing as a factor in most cases.

However, a thin gown or shirt/blouse probably offers little interference and may make the female patient more comfortable during the procedure. The tubing should not be allowed to rub against any objects, because this may produce extraneous sounds.

Auscultation of the lungs should be systematic, including all lobes on the anterior, lateral, and posterior chest. Al, Wilkins et. Clinical Assessment in Respiratory Care, 6th Edition.

Mosby, 022009. A.Continuous-longer duration b.Discontinous-intermittent, bubbly, crackling, short duration Rales vs. Crackles-crackles best used to describe discontinuous sounds d.Wheeze-musical sounds from the chest from obstruction and are continuous e.Rhonchi-harsh, discontinuous sounds from large bronchi from movement of secretions c.Early crackles Occur in larger more proximal bronchi Continue in spite of pt coughing COPD, chronic bronchitis, emphysema, asthma c.Late crackles Sudden opening of peripheral airways and occur in more dependent regions of the lung. May be removed from changing positions or several deep respiratory breaths or cough. Pulmonary edema, pneumonia, atelectasis f.Stridor-high pitched sound that can be heard without the aid of a stethoscope from the neck area and upper airway area. Using appropriate adjectives to describe the BS is important. Such as late inspiratory wheeze, may give importance to the disease state.

G.Pleural friction rub-loud, harsh continuous sound located midaxillary area of lung. Bronchophony-increase in intensity or clarity of vocal resonance due to increase lung tissue density The patient is requested to repeat a word several times while auscultating symmetrical areas of each lung.

The number 'ninety-nine' are commonly used. Easier to detect with unilateral disease.

Associated with bronchial breath sounds, increased vocal fremitus and dull percussion note. Egophony-spoken voice increases in intensity.

Clinical Assessment In Respiratory Care

Pt with a normal voice will say 'E' repeatedly. Normal lung will have the 'E' sound Egophony will have and 'A' sound over area of lung that has consolidation. Also compressed lung from pleural effusion. Chart this as E to A sound indicating consolidation and identify where it was heard. Whispered Pectoriloquy Patient whispers 1-2-3 while listening over lung.

Normal sound is muffled low-pitched and unable to identify the 1-2-3. Consolidation-high pitched sounds over affected area and hear 1-2-3 much clearer. Clubbing of the digits is a significant manifestation of cardiopulmonary disease. The mechanism responsible for clubbing is not known, but it is often associated with a chronic cardiopulmonary disease.

It is identified most commonly in patients with cyanotic congenital heart disease, bronchogenic carcinoma, COPD, cystic fibrosis, and bronchiectasis. Clubbing is characterized by a painless enlargement of the terminal phalanges of the fingers and toes. It requires years to develop. As the process of clubbing advances, the angle of the fingernail to the nail base advances past 180 degrees, and the base of the nail feels spongy. (al 91) al, Wilkins et. Clinical Assessment in Respiratory Care, 6th Edition.

Mosby, 022009.