Physical Assessment

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Physical Assessment

• Respiratory Care 224
• Fall 2003

2
Common Symptoms

• Dyspnea
• Cough
• Sputum Production
• Hemoptysis
• Chest Pain
• Fever
• Pedal Edema

3
Assessment Skills

• How to Perform a Patient Bedside Assessment

4
The 2 Phases of Assessment

• Interviewing the Patient
• Taking a History
• Physical Examination
• Inspection
• Palpation
• Percussion
• Auscultation

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Interviewing the Patient
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Structure of the Interview

• The opening
• Social Space
• Initial Repport
• Personal Space
• 1 to 4 feet away
• Intimate Space
• Where the physical exam takes place

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Questioning Techniques

• Open-ended questions
• Direct questioning
• Closed questioning
• Active listening

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Active Listening

• Checking or Restating
• Emphasizing
• Supporting
• Summarizing
• Reflecting
• Respecting

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Active ListeningVERBAL TECHNIQUES

• Keep tone neutral
• Facilitate with go on and what else
• Echo back in new words
• Paraphrase
• Clarify ideas

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Active listeningNONVERBAL TECHNIQUES

• Eye contact
• Supportive gestures
• Take notes
• Keep an open mind
• Supportive facial expression

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Comprehensive Interview

• Patient History
• Review of systems

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Patient History

• History of Present Illness
• Past Health History
• Current Health Status
• Family History
• Social History

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Common Symptoms of Lung Problems

• Dyspnea- How is your breathing today? (When
  are they S.O.B.?)
• Orthopnea- Have you had to sit up to make your
  breathing easier?
• Cough- What has your cough been like?
• Is it productive? If so, how often? How much
  sputum is coughed-out? What is its color?
  (purulent?- mucoid?) Consistency?

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Common Symptoms of Lung Problems

• Does the patient have any of the following
  complaints?
• Blood in the sputum - (hemoptysis)
• Chest pain - (during breathing?) pleuritis
• Fever
• Usually indicates an infection of some sort

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Past Medical History

• Previous hospitalizations for similar complaint?
• Relevant work history?
• Worked in dirty air environment
• Ever had asthma?
• Smoked? How many cigarettes/day for how many
  years
• Pack years of pack/day x of years

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Review of Systems

• Start systematically from the head down
• Guideline/pattern to follow
• Very similar to physical examination

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Physical Examination
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Inspecting the Patient

• General Appearance
• Wasted? Well-nourished? Obese? Distressed?
  Relaxed? Disheveled? Well-cared-for? Diaphoretic?
  Pale? Cyanotic?
• Level of consciousness
• Oriented to person, time place (x3)
• Obtunded? Lethargic? Confused?

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Inspecting the Patient

• Vital Signs
• Temperature - Febrile? Hypothermic?
• Pulse - Tachycardia? Irregular? Faint? Pulsus
  paradoxicus? Pulsus alterans
• Respiration - Tachypnea? Shallow? Deep?
• Blood pressure - Hypotensive? Hypertensive?
  Syncope?

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Inspecting the Patient

• Examination of Head
• Nasal Flaring
• Cyanosis
• Pursed lip breathing
• Look of anxiety
• Examination of Neck
• Trachea midline?
• Jugular veins distended?

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Examination of the Thorax Lungs

• Thoracic configuration
• Barrel chest?
• Kyphosis
• Scoliosis?
• Kyphoscoliosis?
• Pectus excavatum
• Breathing Pattern Effort
• Retractions? intercostal supraclavicular

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Breathing Pattern Effort continued

• Synchrony of diaphragm upper chest?
• Diaphragm upper chest should work together
• Abdominal paradox - upper chest rises while
  diaphragm falls
• This indicates fatigue of the diaphragm
• Is a excellent predictor of impending
  respiratory failure

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Palpation

• The art of touching the chest wall to evaluate
  underlying structures

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Aspects of Palpation

• Skin subcutaneous tissues
• evidence of subcutaneous emphysema?
• Aka - crepitus
• pain associated with bruising /or rib fractures?
• Vocal fremitus
• Thoracic expansion

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Percussion of the Chest

• Act of tapping on the chest wall (rib
  interspaces) to evaluate underlying structures
• Percussion Sounds
• Dull - indicates fluid or increased tissue
  density
• Hyperressonant (hollow sound) - indicates
  increased air- (heard above a pneumothorax)

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Auscultation of the Lungs

• Listening to body sounds with stethescope

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Auscultation

• Listening to breath sounds
• Stethoscope
• Bell - for low pitched sounds (heart sounds)
• Diaphragm - for higher pitched sounds (breath
  sounds)
• Technique
• Patient breathes through their mouth
• Ideally, sounds on one side of the chest should
  be compared to the opposite side
• May be necessary to have patient roll patient
  side-to-side

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Normal Breath Sounds

• Vesicular sounds
• Soft rustling sounds heard over most lung
  tissue
• Bronchovesicular sounds
• Has characteristics of above two
• Heard only over major airways
• Tracheal sounds
• Hollow tubular sounds

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Abnormal (Adventitious) Breath Sounds

• Crackles (rales)
• discontinuous pop-like sounds
• generally heard on inspiration but can be heard
  on exhalation also
• Wheezes
• high-pitched continuous musical sounds
• can be heard on both inspiration or exhalation

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Abnormal Breath Sounds Continued

• Rhonchi
• low-pitched snoring sound that is continuous
• can be heard on inspiration or exhalation
• Bronchial Breath Sounds
• same as Tracheal Sounds except heard over lung
  parenchyma

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Abnormal Breath Sounds Continued

• Stridor - high pitched raspy sound
• is heard at its loudest over the trachea
• indicates upper airway narrowing
• heard in such conditions as
• post extubation stenosis
• croup in young children

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Abnormal Breath Sounds Continued

• Pleural Friction Rub
• Egophony - e to a changes
• first section heard is the normal e sound
• second sound heard is the example of egophony
  letter e heard as a

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Crackles can indicate

• Atelectasis
• Bronchitis
• Pneumonia
• Pulmonary edema
• Pulmonary fibrosis (dry crackles)

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Ronchi indicates

• Secretions in larger airways
• frequently clear with a cough
• seen in any condition that creates lung mucus
• in COPD ronchi may occur because of airflow
  obstruction unrelated to secretions

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Other Less Common Sounds

• Pleural friction rub
• occurs when pleural surfaces rub together
• seen in some pneumonias effecting pleural
  surfaces
• Stridor
• High pitched rasping sound heard mainly on
  inspiration
• Indicative of upper airway obstruction

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Breathing Patterns

• Cheyne-Stokes Breathing
• Irregular patterns of deep breathing followed by
  periods of shallow breathing usually ending with
  a period of apnea
• Biots Breathing
• Irregular patterns of breathing usually very
  disorganzied. May be periods of apnea
• Kussmauls Breathing
• Rapid deep breathing

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More Breathing Patterns

• Apneustic Pattern
• Prolonged inspirations serial inspirations w/o
  exhalation after each followed by summative
  exhalation
• Asthmatic Pattern
• Excessively long expiratory periods
• Paradoxical Breathing
• Is present when a portion of chest wall moves in
  the opposite direction as it should during the
  breathing cycle

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Voice Sounds

• Egophony
• 1. Place stethoscope over lung area
• 2. Ask patient to say the letter e
• 3. If you actually hear the hard a sound
• 4. The area has a fluid or consolidation
• Bronchophony
• An increase in intensity and clarity of vocal
  sounds.

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Cardiac Sounds

• Lub - Dub
• S1, S2
• PMI (Point of Maximal Impulse)
• Fifth intercostal, mid clavicular, left side
• PVCs are common
• Heaves, gallops, murmurs, bruits

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Abdominal Examination

• Is the abdomen distended?
• Is the abdomen hard when palpating it?
• Increased abdominal pressure can put increased
  pressure on the diaphragm making breathing more
  difficult. Causes
• Hepatomegaly
• Intra-abdominal bleeding

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Examination of the Extremities

• Look for evidence of
• Cyanosis
• hands, feet, mucous membranes
• Pedal edema (pitting edema)
• 1 to 5 scale used
• Clubbing of fingers
• seen in a variety of inflammatory diseases
• Capillary refill
• Peripheral skin temperature

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Clubbing illustrated
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Documentation

• After the interview and the physical examination
• Doctor will
• Write new orders
• Check for previous lab results
• Document visit in the progress notes of the chart
  (SOAP)

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Therapist responsibilities

• Follow correct orders prescribed
• Assess if appropriate
• Give proper report to next shift
• Understand patients care plan
• Be able to work as part of the health care team

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End of Physical Assessment

• Thats all Folks