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Respiratory Assessment To adequately assess a patient’s respiratory condition, a review of the patient’s existing medical condition is warranted. Typically, this is accomplished when a patient arrives at a physician's office, is admitted to a medical facility or a change in condition surfaces. The importance of the assessment reflects a reference point to allow for further assessment of change in the patient’s condition. The primary evaluation includes:
1. General History We all know that the older patient may have a significant history of medical maladies and a prescription medication list that is a full page long. While all of these things are important, a brief history of past illnesses and significant family history is what is needed to complete a respiratory examination or assessment. The assessor will, over time, become aware of the correct questions to ask regarding:
An allergy history is important to document.
She initially presented with wheezing and dyspnea on exertion. A complete physical exam, diagnostic testing, lab work and pulmonary rehabilitation training was instituted. She was asked during her rehab training, if she slept on a feather pillow. The answer was "yes". The patient had undergone a complete work -up and pulmonary rehab training before this question was asked. She was significantly better following the removal of the pillows. The proper use of current medications and patient education, can prevent or reverse airway disorders. An adequate medical and related social background history will play a significant role in a respiratory assessment. A patient may have medical conditions other than primary respiratory which affect the lungs, heart and the kidneys. (The cardiopulmonary system) In addition, patients may have associated reversible airway disease related to allergies or occupational exposure. 2. Symptoms History
A symptom, is a description by the patient, that cannot be determined objectively. They will describe feelings and sensations, the degree to which can only be expressed by the patient. Our interpretation of the symptoms guide us in proper assessment and eventually treatment. Take into consideration that we all have experienced the overactive and/or anxious patient who wants immediate relief and a cure. Your understanding of the patient’s symptom description, combined with a respiratory physical exam will determine a course of action. Specific symptoms include:The Cough
Typically you want to know whether the patient has a productive cough. It is possible that the patient coughs so much, and for so long that their response to the question is "No, I don’t cough". Be observant and ask when the last cold or flu bout has occurred, then continue your discussion regarding quality and quantity of productive coughing. Teach the patient to observe their productive cough. Secretions, mucus, sputum and phlegm.
Secretions may appear clear, whitish and mucoid normally and many patients discuss them as sinus drainage. In such a case, this is your invitation to direct questions regarding the upper respiratory system, prior to the remaining questions, regarding the lung production of secretions. When an infection begins, secretions change to yellow and green in color and increase in the amount and tenacity. (stickiness) Dark red or rusty colored production usually is associated with a pneumococcal infection. While a lighter or brighter red color usually indicates a recent change in the integrity of the airways. A brighter red color may indicate rupture of blood vessels from coughing. Lung cancer and tuberculosis are associated with production of red sputum. Patients with pulmonary edema have thin, watery expectoration which may appear pinkish. Patients with disease like cystic fibrosis and bronchiectasis produce foul smelling yellow and green sputum regularly. It should be noted that foul smelling production is associated with infections like Pseudomonas. These have become more common with the advent of Methicillin-resistant Staphylococcus Aureus (MRSA) and Vancomycin-resistant Enterococci (VRE) infections.Tan, brown and black secretions may be noted with long standing infections or inhaled particulate matter. Dyspnea The sensation of shortness of breath. (Use the abbreviation - shortness of
air or S.O.A.) When is the patient dyspneic or noticeably Short of Air?
*(see appendix for additional scales) For general purposes, shortness of breath may be evaluated at rest, with movement and on exertion. To many patients the body and arm strength using a vacuum cleaner or to wash dishes is considered exertion and is very energy consuming. Exertion is usually measured in debilitated patients by walking or mild exercise. There is a fine line between sleeping, at rest, movement and activity of daily living. The range of dyspnea may be from... short of breath at rest, to... short of breath on the most intense exertion. Determine the initial level, the normal level of dyspnea, and measure changes based on this agreement with the patient and your observation. When dyspnea increases with less exertion than previously noted, the patient is deteriorating. This may subside or continue. Pulmonary rehab programs have concentrated on exercise that will improve the patient's level of dyspnea. Another consideration is, all or most patients will respond to supplemental oxygen and their level of dyspnea will change. Oxygen is energy. Chest Pain
Heart pain relates to what we've been taught about CPR. The classic chest pain of heart disease is described by a burning suffocation or pressure sensation. These sensation's radiate to other areas such as the jaws and arms. A quick question regarding lifting, pulling or physical exertion, which strains a muscle may help your evaluation. The pain of lung disease is described as sharp, stabbing and a pain which worsens with a deep breath or cough. This type of pain is usually associated with the pleura of the lung. During your evaluation, if you think about oxygen
or the lack of oxygen, then it probably is a problem! (see hypoxia and
skin color) Edema
During the progression of lung disease, the right
heart, which pumps blood to the lungs becomes overworked. An enlargement
occurs from excessive muscle activity, which is referred to as
cor-pulmonale. This condition is associated with lung disease and can be
determined by an additional assessment or a diagnostic test. (for example; chest
X-ray or electrocardiogram)
Lung disease patients will continue to complain of shortness of breath, even in an upright position and may haunch over a night stand to relieve the pressure. Either patient may have some relief by sleeping with the head elevated. Note: The current trend during sleep study testing is monitoring heart and lung function. Sleep apnea patients have tremendous stress on their cardio-pulmonary system, so symptoms may be related to primary sleep apnea. In addition, CHF patient's have a predisposition towards sleep apnea. Sleep studies help differentiate predominate heart or lung conditions.
Overall observation Observable Signs - objective and semi objective assessment
Color
When observing for color and due to the various skin pigments of patients, it is often necessary to evaluate for central cyanosis{the nail beds, interior of the mouth and nose, conjunctiva of the eye and/or palmar creases} rather than gross observation. If the skin or mucous membranes appear red and or flushed it may be a sign of polycythemia, blood pressure, allergies or medications taken by the patient. A white sign may indicate anemia, poor circulation or a shocky looking patient. Blue is generally associated with the term cyanosis. It should be noted that cyanosis is a late and unreliable sign, unless accompanied by other signs, symptoms and tests. Examine the head, neck and note signs of central cyanosis. Be aware that room lighting and skin tone effect your observation. Central cyanosis is more reliable to indicate levels of oxygenation than will observing peripheral extremities, due to the variability of circulation to the arms and legs. Peripheral cyanosis or blue discoloration of the hands, fingers or nail bed may or may not be significant. Warm well perfused areas normally will not appear blue. If they do, please note as such. Observe the inside of the lips, cheeks, nose and eye lids. Remember, many Chronic Obstructive Pulmonary Disease{COPD} patients have produced great numbers of red blood cells or polycythemia, which will reflect in the lab tests of the hemoglobin and hematocrit. This red blood cell production is the body's attempt to respond to persistent hypoxemia. If the blood cells are not fully saturated the patient may appear cyanotic, but will not necessarily be hypoxic do to the large number of circulating hemoglobin. Also remember that a hypoxic patient may not be cyanotic. Pay particular attention to other signs and symptoms. In addition jaundice, a yellow color, is primarily observed by examining the sclera of the eye. {unless severe jaundice is present and a yellow color to the patient's skin is evident} Posture
The primary muscle of ventilation is the diaphragm. With additional assistance via the use of the internal and external intercostals, the effort required to breathe, is minor in the normal and is barely observable. The expenditure of energy, or the use of oxygen to breathe, is normally minimal. The effort to breath, regarding a COPD patient, is greatly increased and therefore observable. The patient with lung disease will prefer to sit in the upright position and often try to support their accessory muscle use. It is not uncommon to see these patients deliberately blowing a breath through pursed lips. It may appear that they are conscious of every breath and in fact this may be true. This lends itself to an increased level of anxiety and the use of short sharp statements when responding to questioning. Breathing You have already ascertained breathing style and ability, by the patient’s subjective expression of shortness of breath, now observe for audible signs of breathing, by listening grossly for signs of wheezing, stridor (a high-pitched breathing noise ) or harsh inspiratory/expiratory noises. The upper respiratory area (oro-pharyngeal- laryngeal) is sensitive to inflammation, swelling and secretion production. Air moving through these areas will generate some unsettling audible noises. Causes include airway narrowing, tracheal stricture or excessive secretions. Ask the patient to cough and see if the noises subside or disappear. Suctioning of the oral pharyngeal area is often indicated to aid the debilitated patient. A Closer Inspection
Veins on both sides of the head should be viewed for distention and often indicates inadequate right heart pumping or failure. With the patients head elevated the venous distention indicates elevated venous pressure. COPD patients begin to use pursed lips breathing to provide back pressure in the airway, during exhalation, to prevent airway collapse. The integrity of the airways has deteriorated and tends to collapse more readily than normal. Patients often acquire this technique by default, because it relieves dyspnea or they are taught this as a breathing exercise. Check the eyes for signs of redness and jaundice. Observe the lips, skin and oral mucus membranes for signs of dryness to evaluate hydration. Patients will be encouraged to consume fluids or they may need intravenous fluids. The Chest Cage
The rate of breathing, regularity of breathing and chest excursion or depth of breathing, are important features. Secondly, the non respiratory entities begin to surface when the patient has problems with the central nervous system (CNS), the heart or other body organs.
Deformities of the Chest Physical abnormalities of the chest may effect breathing or they may be caused by lung disease. The chest should appear symmetrical and have an anterior posterior diameter less than the transverse diameter. From the top of the head looking down, the chest resembles more closely to a narrow oval than a circle. With end stage or advanced COPD the anterior posterior diameter will increase, which produces the typical barrel chest. Spinal malformations such as kyphoscoliosis will effect chest expansion, whereas deformities to the sternum will most likely not affect breathing. Recent studies indicate that men are more closely aligned as belly breathers and women are upper chest breathers. This refers to the part of the body, which raises or inflates during at rest inspiration. This most likely relates to weight distribution. Pulmonary rehabilitation teaches using a weight on the abdomen to improve ventilation. Retractions are an inward pulling of the chest during inspiration. This gives the appearance of dys-coordinated breathing and is associated with severe obstruction. The observation of retracted breathing is taught during CPR training, with the recognition of upper airway or foreign body obstruction. The Diaphragm Examine the diaphragmatic excursion for signs of interference. The most common being obesity. The diaphragm is attached to and supports the lungs. It is the major muscle of respiration and moves slightly downward with each breath. The stimulus to do this is regulated by the brain and physiological processes. The abdominal muscles and the intercostals may aid in this process. Severe COPD patients have poor diaphragm movement due to air trapping and obese patients simply have restricted or limited movement. The Extremities Observing the appearance of the arms, hands, fingers, legs and feet indicate a variety of healthy and poor conditions. Peripheral cyanosis is caused by an increased amount of unoxygenated hemoglobin, and not by decreased oxygenated hemoglobin. Therefore cyanosis is an unreliable sign, but should be noted. Cyanosis may be caused by poor circulation, poor cardiac output, peripheral vascular disease or COPD. Check the fingers and nail beds for abnormal signs such as curvature of the nails or finger tips which appear larger or swollen. In addition, the finger nails may thicken. This is referred to as clubbing and is associated with chronic hypoxia caused by COPD or heart disease. Percussion of the Chest Percussion in medicine means tapping with the fingers and is done to assess the presence of air or fluid in the body. Tapping is done with curved fingers like tapping your fingers on a table top. If a hollow or resonant sound is heard over the chest, air is present. Usually a dull or flat sound is heard over bony parts. Therefore, a dull sound heard by tapping over an area of the body that you know is supposed to be air, indicates consolidation or fluid. (or something less than the normal amount of air) The whole key to tapping is to use only the wrists and maintain uniformity in the process. Side to side, top to bottom. Increased air sounds over all lung fields mean a diffuse condition exists or is associated with obstructive airways disease and are referred to as hyper resonant. A specific hyperresonant localization may indicate a pneumothorax. The diaphragm movement may be assessed by tapping on the abdomen, the flat sound, and progressing upwards until a resonant sound is heard. The location of tapping should be uniform on the left and right. Asks the patient to inhale and continue to tap to assess each hemi-diaphragm. The difference in sound is the excursion of the diaphragm. It is important to note whether the diaphragm is moving. Non-inflated areas of the lung (atelectasis) will generate a dull sound. Palpation
Place the hands on the chest, one hand for each side of the chest (left or right) and then slide the hands drawing skin tissue toward the midline of the chest. This holding of the patient's chest allows for comparison of movement, when the patient is asked to inhale. Choose a location which allows the greatest excursion, which is usually the base of the lung. A patient that cannot inflate the base of the lungs equally has a problem with a localized condition. This is often pneumonia or atelectasis. Please note that in a COPD patient, the apices of the lung tend to inflate, which is contrary to normal. Deviations in tracheal position are assessed by placing the finger into the sternal notch and checking both sides for uniformity. Auscultation Auscultation, the act of listening, is an important clinical assessment tool to evaluate a patient’s respiratory function. Please keep in mind the following:
try to create a quiet environment as much as
possible. Eliminate noise by closing the door and eliminating radios or
televisions in the room.
proper position, sitting up in bed, and not leaning against anything. A stethoscope should be touching the patient’s skin when possible. The patient’s clothing may cause rubbing sounds.Always ensure patient comfort. Warm the diaphragm of your stethoscope. When auscultating, consider the
following: To assess the posterior chest, ask the patient
to keep both arms crossed in front of the chest. Auscultate using the
diaphragm of your stethoscope. Ask the patient not to speak, listen
first to normal (regular rate and depth) breathing. Then ask the patient
to breathe deeply through the mouth. Be careful that the patient does
not hyperventilate. You should listen to at least one full breath in
each location. It is important that you always compare what you hear
with the opposite side. There are numerous locations for auscultation
on the anterior and posterior chest. You should listen to at least 4 and try for 6
locations on both the anterior and posterior chest.
Normal Breath Sounds Normal breath sounds are traditionally organized into categories based on their:
Breath sounds are created by turbulent air
flow.
During inspiration, air moves into progressively smaller airways with the alveoli as its final location. As air hits the walls of these airways, turbulence is created and produces sound. During expiration, air is moving in the opposite direction towards progressively larger airways. Less turbulence is created, thus normal expiratory breath sounds are quieter than inspiratory breath sounds. Tracheal Sounds Tracheal breath sounds are very loud and relatively high-pitched. The inspiratory and expiratory sounds are more or less equal in length. They can be heard over the trachea which is not routinely auscultated. Vesicular Breath Sound The vesicular breath sound is the major normal breath sound and is heard over most of the lungs. They sound soft and low-pitched. The inspiratory sounds are longer than the expiratory sounds. Vesicular breath sounds may be harsher and slightly longer if there is rapid deep ventilation (i.e. post-exercise) or in children who have thinner chest walls. Vesicular breath sounds may be softer if the patient is frail, elderly, obese, or very muscular. Bronchial Breath Sound Bronchial breath sounds are very loud, high-pitched and sound close to the stethoscope. There is a gap between the inspiratory and expiratory phases of respiration, and the expiratory sounds are longer than the inspiratory sounds. If these sounds are heard anywhere other than over the manubrium, it is usually an indication that an area of consolidation exists (i.e. space that usually contains air now contains fluid or solid lung tissue). Bronchovesicular Breath Sound These are breath sounds of intermediate intensity and pitch. The inspiratory and expiratory sounds are equal in length. They are best heard in the 1st and 2nd inter costal space (anterior chest) and between the scapula. (posterior chest) As with bronchial sounds, when these are heard anywhere other than over the main stem bronchi, they usually indicate an area of consolidation. Abnormal Breath Sounds Absent or Decreased Breath Sounds There are a number of common causes for absent or decreased breath sounds, including:
Bronchial Breath Sounds in Abnormal Locations Bronchial breath sounds occur over consolidated areas. Further testing of egophony and whispered petroliloquy may confirm this. Adventitious Breath Sounds Adventitious - Abnormal Adventitious sounds are those that are normally not heard coming from the chest. Crackles (Rales) Crackles are discontinuous, nonmusical, brief sounds heard more commonly on inspiration. They can be classified as fine (high pitched, soft, very brief) or coarse (low pitched, louder, less brief). When listening to crackles, pay special attention to their loudness, pitch, duration, number, timing in the respiratory cycle, location, pattern from breath to breath, change after a cough or shift in position. Crackles may sometimes be normally heard at the anterior lung bases after a maximal expiration or after prolonged recumbency. The mechanical basis of crackles: Small airways open during inspiration and collapse during expiration causing the crackling sounds. Another explanation for crackles is that air bubbles through secretions or incompletely closed airways during expiration. Conditions Wheeze Wheezes are continuous, high pitched, hissing sounds heard normally on expiration but also sometimes on inspiration. They are produced when air flows through airways narrowed by secretions, foreign bodies, or obstructive lesions. Note when the wheezes occur and if there is a change after a deep breath or cough. Also note if the wheezes are monophonic (suggesting obstruction of one airway) or polyphonic (suggesting generalized obstruction of airways). Conditions Rhonchi Rhonchi are low pitched, continous, musical sounds that are similar to wheezes. They usually imply obstruction of a larger airway by secretions. Stridor Stridor is an inspiratory musical wheeze heard loudest over the trachea during inspiration. Stridor suggests an obstructed trachea or larynx and therefore constitutes a medical emergency that requires immediate attention. Pleural Rub Pleural rubs are creaking or brushing sounds produced when the pleural surfaces are inflammed or roughened and rub against each other. They may be discontinuous or continuous sounds. They can usually be localized at a particular place on the chest wall and are heard during both the inspiratory and expiratory phases. Conditions Mediastinal Crunch (Hamman’s sign) Mediastinal crunches are crackles that are synchronized with the heart beat and not respiration. They are heard best with the patient in the left lateral decubitus postion. As with stridor, mediastinal crunches should be treated as medical emergencies. Conditions pneumomediastinum APPENDIX Rate of Dyspnea (shortness of breath) This scale measures your perception of how short of breath you feel at rest and during activity. This scale was developed so that you may translate into a number value your feelings of shortness of breath. There are no wrong answers. This number represents how your breathing feels to you. Keep in mind that "0" means that you are breathing without thinking about it and normally for you and "10" is the most out of breath you can imagine. Your level of shortness of breath may correlate with the level of saturation and can be an effective way for you to monitor yourself during exertion.
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Following an initial assessment, a patient was placed in
a pulmonary
rehabilitation training program. 
