Unit 2- Assessment

1. RTH 112
Assessment
Unit 2

2. Text Reference
• Egan 9th Edition
– Chapter 15 “Bedside Assessment of the
Patient”

3. Objectives
• Write a brief summary explaining the importance
of conducting a patient interview in 500 words or
less
• Without the use references, list the major
components of a health history
• Using the notes, review the techniques to conduct
a patient interview
• Without the use of references, summarize the
importance of conducting a physical examination
• Verbally describe the four major examination
techniques

4. Patient Evaluation
• Initial Assessment
– Clinical Manifestations
• Patient Interview
• Physical Examination
• Secondary Assessment
– Diagnostic Studies
• Arterial Blood Gases
• Pulmonary Function Studies
• Chest Films
• Other Diagnostic Procedures as Indicated

5. Patient Interview
• Determine Level of Consciousness
– Normal: alert & cooperative
– Lethargic
– Confused
– Obtunded: diminished cough or gag
– Semi-comatose: responds to painful stimuli
– Coma: unresponsive to pain

6. Patient Interview
• Orientation of time, place and person
– Well oriented, cooperative
• Able to follow simple commands
– Disoriented, confused
– Inability to cooperate:
• Language difficulties
• Influence of medications
• Hearing loss
• Fear, depression

7. Patient Interview
• Assess Emotional State
– Anxiety
• Respiratory distress, hypoxemia
– Depression
• Quiet or withdrawn, in denial
– Anger
• Combative, irritable
– Euphoria
• Influence of drugs
– Panic
• Hypoxia, air hunger, status asthmaticus

8. Patient Interview
• Measure Subjective Symptoms
– Orthopnea
• Difficulty breathing except in upright position
– General Malaise
• Run down, nausea, weakness, fatigue
– Dyspnea
• Feeling SOB
– Grade I: normal dyspnea after unusual tension
– Grade II: breathless after going up hill or stairs
– Grade III: dyspnea while walking at normal speed
– Grade IV: dyspnea moving slowly & short distances
– Grade V: dyspnea at rest, small tasks

9. Patient Interview
• Pain
– Location
– Quality (what kind is it)
– Severity
– Aggravating factors
– Relieving factors
– History (when did it start and how did it progress)
– Context (circumstances of onset)
– Accompanying Symptoms

10. Patient Interview
• Symptoms of Nose and Throat
– Nasal secretions
• Amount
• Irritants, allergies
– Itching or burning sensation of nose and throat
– Dysphagia
• Difficulty swallowing
• Hoarseness

11. Patient Interview
• History of present illness
– Current medical/physical problems
– Current meds, including herbs, etc.
• Past medical history
– Previous medical problems, hospitalizations,
surgeries, drug allergies, etc
• Family history
– Heart disease, diabetes, COPD, etc.

12. Interview Techniques
• Ask open ended questions
– No yes or no questions
• Communicate using simple language
– KISS Method
– Use pictures, diagrams
– Interpreter for those with language barriers

13. Physical Examination
• Begin with Assessment by Inspection
– What Can You See?

14. Assessment By Inspection
• General Appearance
– Age
– Height
– Weight
– Sex
– Nourishment

15. Assessment By Inspection
• Peripheral Edema
– Presence of excessive fluid in the tissue
– Pitting Edema
– Occurs primarily in arms and ankles
– Caused by CHF, Renal insufficiency/failure
– Rated +1, +2, +3
• The higher the number, the greater the swelling

16. Peripheral Edema
Abnormal buildup of fluid in the ankles, feet, and
legs is called peripheral edema.
Foot with Edmea Normal Foot

17. Assessment By Inspection
• Clubbing of fingers
– Suggestive of pulmonary disease
– Caused by chronic hypoxia
– Can affect thumb, fingers and toes
– Condition is present when the angle of the nail
bed and skin increases

18. Assessment By Inspection
• Venous Distention
– Occurs with CHF
– Seen in patients with obstructive lung disease
– Seen during exhalation because of the
obstructive component

19. Assessment By Inspection
• Capillary Refill
– Quick check of perfusion
– Blanching of hand or nail beds and watch for
blood return
– Normally 3-5 seconds
– Commonly performed for the Allen’s Test
before arterial blood gas puncture

20. Assessment By Inspection
• Diaphoresis
– State of perfuse/heavy sweating
– Heart failure
– Fever, infection
– Anxiety, nervousness
– Tuberculosis (night sweats)

21. Assessment By Inspection
• Skin Color
– Normal: pink
– Abnormal: pale
• Due to anemia or blood loss
– Jaundice: yellow
• Increase in bilirubin, mostly face & trunk
– Erythema: redness
• Capillary congestion, inflammation, infection
– Cyanosis: blue/gray
• Hypoxia (5 g of reduced hemoglobin)

22. Assessment By Inspection
• Chest Configuration
– Normal: A-P diameter
• Straight spine, no alterations in chest size
– Pectus Carinatum
• Anterior protrusion of the sternum
– Pectus Excavatum
• Depression of the sternum
– Kyphosis
• Hunchback or convex spine curve
– Scoliosis
• Lateral curve of the spine
– Kyphoscoliosis: combination of both
– Barrel Chest
• Increased A-P diameter resulting form air trapping

23. Assessment By Inspection
• Movement of Chest/Diaphragm
– Symmetrical movement
– Unequal movement
• Chronic lung disease
• Atelectasis
• Pneumothorax
• Flail Chest – paradoxical
• Intubated with ET tube in one lung

24. Assessment By Inspection
• Breathing Patterns
– Eupnea – normal rate, depth, rhythm
– Tachypnea- over 20 bpm
• Fever, hypoxia, pain, CNS problem
– Bradypnea- less than 8 bpm
• Variable depth and irregular rhythm
– Apnea- cessation of breathing
– Hyperpnea- increased rate & depth, regular
rhythm
• Metabolic/CNS disorders

25. Assessment By Inspection
• Breathing Patterns
– Cheyne Stokes- gradual increasing the decreasing rate
and depth in a cycle with periods of apnea
• Increased ICP, Meningitis, overdose
– Biots- increased rate and depth with irregular periods of
apnea
• CNS problem
– Kussmauls- increased rate (>20) increased depth,
irregular rhythm, seems labored
• Metabolic acidosis, renal failure, diabetic ketoacidosis

26. Assessment By Inspection
• Breathing Patterns
– Apneustic- prolonged gasping inspiration
followed by extremely short, insufficient
expiration
• Problem with respiratory centers, trauma or tumor

27. Assessment By Inspection
• Muscle use
– These muscles are used to increase ventilation
during times of stress, increased airway
resistance, etc.

28. Assessment By Inspection
• Muscle Use
Muscles used during Normal Breathing
– Diaphragm
– External Intercostals
– Exhalation is passive

29. Assessment By Inspection
• Accessory Muscle Use
– Used to increase ventilation
Muscles of normal ventilation PLUS
• Intercostals, scalene, sternocleidomastoid, PLUS
• Abdominal muscles

30. Assessment By Inspection
• Retractions
– Chest moves inward during inspiration instead of
outward
– Due to a blocked (obstructed airway)
– A sign of respiratory distress in infants
• Nasal Flaring
– Flaring of the nostrils during inspiration
– A sign of respiratory distress in infants sometimes
accompanied by grunting

31. Assessment By Inspection
• Character of Cough
– Strong, moderate, weak
– Productive, nonproductive
– Frequent, infrequent
– Tight, moist

32. Assessment By Palpation
• Pulse
– Normal: 60-100
– Tachycardia: >100
– Bradycardia: <60
– Adverse Reaction: >20 Increased HR
– Monitor rhythm

33. Assessment By Palpation
• Tracheal Deviation
– Pulled toward pathology (inside lung)
• Atelectasis
• Pneumonectomy
• Diaphragmatic paralysis
– Pulled away from pathology (outside lung)
• Massive pleural effusion
• Tension Pneumothorax
• Neck or thyroid mass
• Large mediastinal mass

34. Assessment By Palpation
• Tactile Fremitus
– Vibration felt by hand on the chest wall
• Vocal fremitus-voice vibrations on the chest wall
• Pleural rub fremitus – grating sensation due to
roughened pleural surfaces rubbing together
• Rhonchial fremitus – secretions in the airway

35. Assessment By Palpation
• Tenderness
– Around suture sites, chest tubes, fractures
– Avoid areas of tenderness if possible

36. Assessment By Palpation
• Chest Motion Symmetry
– Hands placed on the patient’s chest move in
symmetry. If one hand moves more than the
other, it indicates asymmetrical chest expansion

37. Assessment By Percussion
• Performed by placing the middle finger between
two ribs and tapping the middle finger’s first joint
with the middle fingers of the opposite hand.
– Resonance- normal air filled lung; hollow sound
– Flat- over sternum, muscle or atelectasis; full sound
– Dull-fluid filled organs; pleural effusion or pneumonia;
thudding sound
– Tympany-air filled stomach; drum like sound
– Hyperresonance-Areas of the lung with pneumothorax
or emphysema. Booming sound.

38. Assessment By Auscultation
• Normal Breath Sounds- vesicular
– Bilateral vesicular: normal in both lungs
– Bronchial vesicular: normal over the trachea or
bronchi

39. Assessment By Auscultation
• Increased, decreased, unequal or absent
– Always compare one lung with the other
– Egophany: “E” sound like “A”. Consolidation
– Bronchophony & whispered pectoriloquy: increased
intensity of voice when spoken. Indicated
consolidation and pneumonia
– An increase in voice indicates consolidation and
pneumonia
– A decrease in voice indicates obstructed bronchi,
pneumothorax, emphysema

40. Assessment By Auscultation
• Abnormal Breath Sounds – adventitious
– Rales (crackles)- fluid/secretions
• Coarse (rhonchi)- large airway secretions
– Suction the pt/cough
• Medium
– Pt needs CPT
• Fine (moist crepitant rales)- alveoli fluid
– Pt has CHF/pulmonary edema
– PT needs IPPB, heart drugs, diuretics and oxygen

41. Assessment By Auscultation
• Wheezes
– Bronchospasm
– Patient needs a bronchodilator
– Unilateral wheezes indicative of FBO

42. Assessment By Auscultation
• Stridor
– Upper Airway Obstruction
• Supraglottic swelling (epiglottitis)
• Subglottic swelling (croup, post extubation)
• Foreign body aspiration
– Treatment
• Topical decongestant (racemic epinephrine)
• Suction/bronchoscopy
• Intubation for severe swelling and epiglottitis

43. Assessment By Auscultation
• Pleural Friction Rub
– Caused by infection
– A coarse grating or crunching sound
– Inflamed visceral and parietal pleural surfaces
rubbing together
– Associated with pleurisy, TB, pneumonia,
cancer, etc.
– Treat with steroids, antibiotics as indicated

44. Breath Sounds Review
http://Breath Sounds Review

45. Reference Link
• The Lung Exam