PATIENT ASSESSMENT

TABLE OF CONTENTS
(click on the links below to view more details)

   Learning Objectives

   Introduction

   Evaluation

   Patient Interview

   Medical History Taking

   Observation

   The Actual Physical Examination of the Patient

   Special Tests

   Chest X-ray Analysis

   Sputum Analysis

   Microbiologic Tests

   Carbon Dioxide Challenge Test

   Testing Patients’ Pulmonary Function (PFTs)

   Arterial Blood Gas Analysis (ABG’s)

   Ventilation/Perfusion Lung Scanning

   Interpreting Laboratory Test Data

   Tuberculosis

   Primer on Basic Concepts of ECG

   Glossary

   Post Test

   Learning Objectives

Upon successful completion of this course, and given an open-book, multiple-choice exam, you will be able to correctly answer a minimum of 90% of the test items requiring you to:

• Identify and demonstrate methods for conducting a physical assessment of the patient,
• List and discuss the important elements of interviewing a patient and taking a medical history, including how to document the information.
• Identify and explain the purposes of chest roentgenography and key laboratory tests employed in patient assessment, with an emphasis on pulmonary tests
• Discuss the procedures and purposes of sputum examinations
• Identify and explain the techniques for pulmonary function testing
• Identify and explain the purposes of laboratory tests used in patient assessment

   Introduction

Physicians have traditionally had sole responsibility for assessing patients, making a diagnosis, and prescribing protocols for care. In the past, the gathering of patient data, subsequent interpretation of that data, and prescription of therapies was the sole domain of physicians.

Other allied health professionals (nurses, physician assistants, and respiratory care practitioners) have historically had the option of communicating with attending physicians regarding the patient’s prescribed therapeutic regimen. However, lack of confidence and fear of having their input rejected (and possibly disrespected) has inclined many allied health professionals to remain silent. This resulted in the prescription and performance of numerous costly and unnecessary procedures.

Progress in the science and technologies relating to patient assessment has placed increasing demands on non-physician health care professionals (from RNs and LVNs to Respiratory Care Practitioners). The integration of assessment with treatment is a necessary outcome of the growing complexity of the roles and functions being assumed by these non-physician caregivers.

It is no longer acceptable to initiate or alter therapy or treatments without careful consideration of the underlying disorder and its clinical manifestations. Since it is not possible for physicians to be experts in all the fields in which their allied health companions practice, decisions regarding when to begin, change, or end treatments or therapies must be based on tangible clinical evidence, with input from all caregivers.
Although the physician has primary responsibility for these decisions (not unlike the “captain of the ship” concept), other caregivers must participate in the clinical decision-making process. In order to fulfill this role effectively, health care proffesionals must assume responsibility for gathering and interpreting relevant patient data.

These non-physician caregivers have historically had the option of communicating with attending physicians regarding the patient’s prescribed therapeutic regimen. Lack of confidence and sometimes even fear of having their input rejected (and possibly disrespected) has inclined many caregivers to remain silent. This has resulted in the prescription and performance of numerous costly and unnecessary procedures (especially in the area of patient’s respiratory care).

Author’s Note:
In this course, the terms nurses, RCPs, and caregivers are used interchangeably because all the terms refer to non-physician health care professionals who are trusted licensed professionals and whose sole purpose is to provide health care. In addition, there are a wide variety of examinations and techniques included. While some of you may not be concerned with or ever perform all of these, we have tried to make the information here as comprehensive as is possible in a review course. It is our hope that even after you are finished taking the course, you will find this a useful reference tool to keep on hand.

In recent years, however, the nation-wide heightened focus on controlling health care costs, and the increasingly sophisticated training received by caregivers have led to considerably expanded roles, especially in the delivery of health care services. Nursing was among the first of various specialty groups to take on more patient assessment responsibilities. With the advent and proliferation of therapist-driven protocols, physicians have come to depend on both nurses and respiratory care practitioners for identifying appropriate respiratory care and evaluating the effects the therapy is having on the patient.

In recognition of this expanded role for non-physician caregivers, even the new matrix for the national exam for respiratory therapists indicates that caregivers should be able to "determine the appropriateness of the prescribed respiratory care plan and recommend modifications where indicated...(caregivers should be able to) analyze available data to determine pathophysiologic state (of patients), review planned therapies, establish therapeutic goals, determine appropriateness of prescribed therapies and goals...(and) recommend changes in therapeutic plans if indicated, based on (patient) data."

"Patient data" and how to interpret it is the focus of this continuing education unit. Nurses have their practice guidelines to follow regarding assessing the well-being of patients, and RCPs have their therapist-driven protocols which are based on respiratory practitioners being able to analyze available patient data to determine their pathophysiological state. This requires having excellent observational and clinical evaluation skills.

Learning Objectives

Upon successful completion of this course, and given an open-book, multiple-choice exam, you will be able to correctly answer a minimum of 90% of the test items requiring you to:

• Identify and demonstrate methods for conducting a physical assessment of the patient,
• List and discuss the important elements of interviewing a patient and taking a medical history, including how to document the information.
• Identify and explain the purposes of chest roentgenography and key laboratory tests employed in patient assessment, with an emphasis on pulmonary tests
• Discuss the procedures and purposes of sputum examinations
• Identify and explain the techniques for pulmonary function testing
• Identify and explain the purposes of laboratory tests used in patient assessment
  

   Evaluation

The evaluation of patients calls for the application of all the skills of the trained professional. Some of the more important characteristics of the patient’s condition that may be detected by a careful and skilled observer include: the patient’s physical appearance, respiratory status, and even his/her apparent mental and emotional state.

Evaluation of those characteristics requires the caregiver to have in-depth knowledge of respiratory diseases and their symptoms. The caregivers must also be able to recognize the physical changes that occur in pulmonary patients, and be aware of the types of "complaints" those changes generate.

The health care professional must be aware of the wide variety of diagnostic tests available today, especially those relating to lung function, and be able to ascertain and quantify abnormalities shown on test results. The caregiver is responsible for assessing patients for changes in cardio-pulmonary status, for performing an overall physical assessment, and for interpreting available clinical data including the patient’s hemodynamics, chest x-rays, EKGs, and data from lab tests. In brief, caregivers must be proficient in gathering patient data, analyzing it, and providing a valid interpretation for other health care professionals.

Documentation

It is also important that health care professions know how to document their findings. One of the most commonly used formats used for documenting patient data is as follows:

• Record when the patient was evaluated, including: day, month, year, and time)
• Document the original diagnosis, and indicate when the symptoms first occurred (if available), and record any problems that are secondary to the primary diagnosis
  While the format in which the information is recorded varies from institution to institution, it generally includes:
• Subjective assessment: based on the interview with the patient, including his own observations and descriptions of the complaint or symptoms.
• Objective data: based on the information obtained from x-rays, diagnostic exams, and notes from the physician and nurse
• Patient evaluation: record the results of the interview, visual assessment, percussion, auscultation, and palpation
• Document the original treatment plan, and document the clinical and therapeutic objectives of that plan
• Patient response: record how the patient responds to application of the therapy
• Document recommendations regarding continuance, modification, or discontinuance of the therapy; if applicable, record recommendations for additional tests and the results of communications with other members of the health care team
• Record the patient assessment in the procedures column of the patient’s Therapy Procedure Log
• Some of the most useful methods of gathering data regarding patients involve the interview, history-taking, and physical examination. While it is at best difficult to separate the three since they often all occur simultaneously in the clinical setting, for the purposes of this CEU module we will try to examine their important characteristics as separate entities.

   Patient Interview

The interview takes place at the very beginning of the relationship with patients. The practitioner simply proceeds to ask the patient about the nature of his/her problem or complaint. This patient interview can reveal important information relating to symptoms, the patient’s emotional/mental state, and his/her own perception of the problem. The interview is when questions regarding complaints of cough and dyspnea are clarified. Signs of distress during the interview include: the patient sitting forward or in a braced position, anxious or fearful facial expressions, rapid respiratory rates, and interrupted speech patterns.

The purposes of the initial patient interview are to establish rapport, identify the functional status of patient, elicit assessment data, and introduce therapy. You’ve probably heard it said that "how" you say something is often as important as "what" you say. In that vein, before we discuss the types of questions you should ask during the initial patient interview, let’s review interviewing techniques and how to structure the interview.

A basic but important aspect of interviewing involves the caregiver being able to convey genuine concern for the patient’s well-being. Empathy towards the patient can be expressed in several ways. For example, establishing good eye contact during the interview not only lets patients know you are interested in what they are saying, but helps the health care professional control the interview.

Patients can easily sense when a practitioner is doing the minimum, or just "doing his job" and has no sincere interest in their problems. Clinicians who have this approach not only turn off the patient, but also frequently overlook potentially significant information. As a result, their assessment of the patient is incomplete, inaccurate, and often leads to the prescription of inappropriate or unnecessary treatments.

Another way caregivers can convey their genuine concern for the patients’ condition involves how they ask questions during the interview. Posing questions that can be answered with a simple "yes" or "no" is usually inappropriate, counter-productive, and fails to encourage productive communication. An interview that employs more open-ended questions calling for extended responses encourages the patient to "open-up", and reveals information that facilitates an accurate patient assessment. When appropriate, the use of touch may also be an effective means of demonstrating empathy during an interview.

Structuring the Interview

In order to increase the chances of a successful outcome for the interview, even the briefest of patient assessment interviews needs to have a pre-established structure. The nature and content of the questions that will be asked during the interview require an environment that is private and quiet in order to encourage honest and effective communications.

Prior to entering a patient’s room, you should prepare your thoughts so that you’re ready to ask appropriate questions that will enable you to obtain pertinent clinical information. If you’re well organized, you’ll be able to avoid repeating questions and won’t forget to ask key questions. Whenever possible, the setting for the interview should allow for a face-to-face conversation. You should begin the interview by addressing the patient by name, introducing yourself, and explaining your role and the purpose of the interview. This should start the process of putting the patient at ease regarding what is going on.

Observing the patient closely and listening closely during the interview is crucial to your ability to identify his/her mood, level of intelligence, and general state of well-being. Acutely ill or apparently anxious patients may need some reassurances prior to starting in-depth questioning.

Interview Techniques

As an experienced professional accustomed to conducting patient interviews, you probably have adopted a series of questions that you have found works well. This discussion is meant as a review, and may be helpful if you’ve possibly gotten into a rut in your questioning routine. There are several types of questions you can employ to assess patients. A brief review of the types of questions is helpful since each has its place in certain situations.

The most common questions are called direct questions. These are ones that patients can answer with a simple yes or no, or with specific, brief information. Direct questions are most useful in short interviews to assess the patient’s progress toward therapeutic goals. These questions keep the patient focused on relevant topics and help shorten the conversation. It is possible however, to overuse direct questions, causing patients to feel overwhelmed and giving them the sense that you are rushed and aren’t really concerned about their condition.

It is important to word direct questions carefully since most patients tend to answer yes if they think that’s the answer you want to hear. For example, if you ask patients whether their breathing has improved today, they may automatically answer "yes" because they think that is the answer you want to hear. A better way to phrase the question may be to ask, "Are you feeling any better today?" If the patient’s answer is yes, you can counter by asking, "In what way do you feel better today?" This gives the patient an opening for more detailed information without feeling any pressure from you.

It is up to you to not only to ask the right questions in a proper manner, but also to recognize the significance of the patient’s responses to your questions. That is what makes open-ended questions more useful than direct questions. Open-ended questions tend to encourage patients to be more open and talkative about their health concerns they are particularly useful for the initial interview to identify the various symptoms and details pertaining to their complaints.

Questions like "Under what conditions do you feel a shortness of breath?" tend to encourage patients to offer more information than do direct (and somewhat limiting) questions like "Do you ever feel shortness of breath?" Open-ended questions, however, may not result in identifying all the important details since this type of questioning does not direct the patient. The most effective and productive interview contains a combination of direct and open-ended questions.

Interview Topics

Many of the questions posed during the initial interview pertain to the patient’s medical history, including:

• Demographic information, including: patient’s name, date of birth, nationality, occupation, marital status, religious affiliation, and referral source.
• Patient’s answers and brief self-descriptions of physical condition to questions posed during the interview, including:
• Chief complaint: What made the patient decide to seek medical assistance--in his own words, and your comments.
• Present illness: Record the patient’s and your description of current symptoms, when they first occurred and whether they have gotten worse or better with time. Be sure to include a description of the location, frequency and duration of occurrence, severity of pain, and identification of the factors that contribute to an increase or diminution of the symptoms.

Caregivers should take special note of problems involve patient’s cardiopulmonary system, asking him about the following:

• Cough: Does the patient have a cough? If so, so does he/she describe it as severe, moderate, or slight? If you observe the cough, record your evaluation. Ask patients how long they’ve had the cough, when is it the worst, the least. Document the cough’s characteristics: hacking, dry, productive of mucus or phlegm, etc. If they cough up blood, determine the exact amount, color, and consistency of the blood.
• If the patient has Hemoptysis (expectoration or coughing up of blood or bloody sputum from the lungs), this can be significant in the diagnosis; however, you need to be aware not to confuse Hematemesis (vomiting of blood) with hemoptysis.
• Dyspnea: Does the patient ever feel short of breath, during rest or physical activity? Ask him to describe the degree of shortness of breath on an imaginary scale of one to ten.

Dyspnea is the subjective sensation of a shortness of breath. The person with dyspnea consciously experiences symptoms of difficult, labored, and uncomfortable breathing in conditions other than heavy exercise. The experience of dyspnea is subjective and is influenced by the patient's reactions and emotional state at the time. Only the patient can determine its severity.

Dyspnea can be either acute or chronic and can be associated with a vast array of diseases such as respiratory, cardiac, endocrine, renal, neurologic, metabolic, hematologic, and even psychologic disturbances. Treatment must be directed to discovering and treating the underlying cause.

If the dyspneic episode is acute then every action must be taken to secure the patient's airway and provide oxygenation and ventilation. Causes of acute dyspnea may include airway obstruction, pneumothorax, pulmonary embolus, pulmonary edema, pneumonia, asthmatic attack, pulmonary hemorrhage, or even anxiety. In acute cases of dyspnea, the problem will go away when the underlying cause is resolved.

In chronic lung disease such as COPD and various fibrotic lung diseases the dyspnea may never go away. In these cases, the treatment of the underlying process will not always alleviate the symptoms of dyspnea. Causes for chronic dyspnea may include airway disease, lung parenchymal disease, pulmonary vascular disease, pleural process, chest wall abnormality, anemia, deconditioning, cardiac disease, thyroid disease, or neuromuscular disorders.

Clinical assessment of the patient should be made from a thorough physical assessment along with a patient history. Using muscles of respiration is an obvious indication of dyspnea along with tachycardia, diaphoresis, and tachypnea. A bilateral paradoxical breathing pattern is often a sign of possible respiratory failure. Auscultation of the airways will also be important to reveal constricted airways and consolidation as a cause for the dyspnea.

Important questions to ask the patient should include: when the dyspnea started, whether the onset was gradual or abrupt, where the patient was, what the patient was doing at the time, severity of the symptoms, any possible precipitating factors, any changes in the patient's health status, coughing and sputum production, and any associated symptoms such as chest pain, change in consciousness, etc.

A pulse oxygen saturation reading is a good beginning measurement along with routine vital signs. This can then be followed up with more detailed laboratory tests such as arterial blood gases, blood analysis, and an EKG among other things.

Episodes of dyspnea can easily lead to feelings of anxiety and panic, which then creates more shortness of breath. When the patient feels that he cannot get enough air anxiety increases, which increases respiratory rate and oxygen demands. This vicious cycle worsens the dyspnea.

Techniques to break the cycle of dyspnea will include providing reassurance that something is being done to provide relief, instructing the patient to use purse-lip breathing techniques to gain control of his breathing, maintaining the patient in a Fowler's position to allow maximum lung expansion, encouraging relaxation techniques, along with providing medication and oxygen therapy.

American Thoracic Society Grade of Breathlessness Scale

Grade – Degree - Description of breathlessness

0 – None - Not troubled except during strenuous exercise

1 – Slight - Troubled when hurrying on level ground or walking up a                      slight hill

2 – Moderate - Walks slower than people of the same age on level
                            ground because of breathlessness or has to stop for
                            breath when walking at own pace on level ground

3 – Severe - Stops for breath after walking about 100 yards or after                        a few minutes on level ground

4 - Very Severe - Too breathless to leave the house or breathless
                                when dressing and undressing

• Wheezing: This involves emission of a whistling-like sound resulting from narrowing of the lumen of a respiratory passageway. Ask and observe if the patient is wheezing. If so, inquire as to when it appears to occur most and what seems to provoke it.
• Chest Pain: Do they experience it? If so, ask where it’s located, is the onset sudden, does breathing deeply breathing or coughing aggravate it?
• Locomotor System: Does the patient ever experience pain when using his muscles or moving his joints? Is he currently experiencing such pain?
• Nervous System: Ask the patients if they are currently experiencing any headaches, muscle weakness, dizzy feelings, faintness, seizures or convulsions, tremors, vertigo, diplopia, paralysis, paresis, or ataxia.
• Psychiatric Problems: Ask if they are currently feeling particularly nervous, stressed, having episodes of depression, having trouble sleeping or nightmares, or suffering any memory loss.
• Anorexia and Weight Loss: Ask if the patient has recently experienced a loss of appetite, with an attendant loss of weight. This can be very relevant to making a proper diagnosis of respiratory problems.
• Night Sweats: Ask if the patient is experiencing excessive perspiration during sleep at night. If so, ask specific questions regarding the location and characteristics of the perspiration, including odor.
• Digestive System: Ask if the patients are having trouble digesting their meals. Are they experiencing nausea, or vomiting? Does their digestive system involve excess gas or belching, excessive stomach sounds? Do they have difficulty swallowing, and do they experience dark or bloody stools?
• Genitourinary System: Ask if the patients are experiencing any pain or difficulty urinating, are incontinent, have any renal stones, or urinary infections.
• Endocrine System: Ask if the patient is diabetic, has intolerance to heat or cold, or has recently experienced any change of voice.
  

   Medical History Taking

General Considerations

Remember that there are two halves to each interview, patient-centered and caregiver-centered.

Opening the Interview

It is important to begin each medical interview with a patient-centered approach.

1. Set the Stage
     o Welcome the patient - ensure comfort and privacy
     o Know and use the patient's name - introduce and identify yourself
2. Set the Agenda
     o Use open-ended questions initially
     o Negotiate a list of all issues - avoid detail!
          § Chief complaint(s) and other concerns
          § Specific requests (i.e. medication refills)
     o Clarify the patient's expectations for this visit - ask the patient         "Why now?"
3. Elicit the Patient's Story
    o Return to open-ended questions directed at the major problem(s)
    o Encourage with silence, nonverbal cues, and verbal cues
    o Focus by paraphrasing and summarizing
4. Make the Transition
    o Summarize the interview up to that point
    o Verbalize your intention to make a transition to the physician-centered interview

History of Present Illness

Primary History

You should always begin the caregiver-centered phase of the interview with "WH" questions (where? what? when?) directed at the chief complaint(s). Build on the information the patient has already given you. Flesh out areas of the story you don't fully understand. Try to quantify whenever possible (pain on a scale of 1 to 10, number of days instead of "a while," etc.). Be as specific as possible and try to record what the patient says accurately, without interpretation. Address as many of these details as appropriate:

1. Location
2. Radiation
3. Quality
4. Quantity
5. Duration
6. Frequency
7. Aggravating Factors
8. Relieving Factors
9. Associated Symptoms
10. Effect on Function

Secondary History

The secondary history expands on the primary history, especially any associated symptoms. It is useful to think of the secondary history as a focused review of systems (see below). These questions often bring out information that supports a certain diagnosis or helps you gauge the severity of the disorder. Unlike the primary history, a certain amount ofinterpretation (and experience) is necessary. Here are some examples:

Headache
Ask about nausea and vomiting.
Ask about visual changes.
Ask about the relationship with stress, work, weekends, and emotions.

Ear Problems
Ask about hearing loss or ringing in the ears.
Ask about dizziness or vertigo.

Tertiary History
The tertiary history brings in elements of the past medical history (see below) that have direct bearing on the patient's condition. By the time you get to the tertiary history you may already have a good idea of what might be going on. (This will be fine-tuned by the physical exam.) Here are some examples:

Any HEENT or Chest Disorder
Does the patient smoke? How much? How long?
For children, does someone smoke in the home?

Breast Problems
Is there a family history of breast cancer?

Abdominal Pain
Does the patient smoke? How much? How long?
How much alcohol does the patient consume?
Prior surgery? Has the appendix been removed?

Chest Pain
Does the patient smoke? How much? How long?
Did the patient's parents die of a heart attack? At what ages?

Review of Systems

The review of systems is just that, a series of questions grouped by organ system including:

1. General/Constitutional
2. Skin/Breast
3. Eyes/Ears/Nose/Mouth/Throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Neurologic/Psychiatric
10. Allergic/Immunologic/Lymphatic/Endocrine

Past Medical History

The past medical history is essentially background information related to the patient's health and well being. A brief past medical (and social) history often includes these elements:
1. Allergies and Reactions to Drugs (What happened?)
2. Current Medications (Including "Over-the-Counter")
3. Medical/Psychiatric Illnesses (Diabetes, Hypertension, Depression, etc.)
4. Surgeries/Injuries/Hospitalizations (Appendectomy, Car Accident, etc.)
5. Immunizations
6. Tobacco/Alcohol/Drug Use
7. Reproductive Status for Females
    o Last Menstrual Period
    o Last Pelvic Exam/Pap Smear
    o Pregnancies/Births/Contraception
8. Birth History/Developmental Milestones for Children
9. Marital/Family Status
10. Occupation/Exposures

For more on Past Medical History, be sure to ask the patient for information regarding:

• Past Illnesses, including: recurrent episodes of pulmonary infections, infectious diseases, infantile eczema, atopic dermatitis, accidents, allergic rhinitis, or co-existing conditions such as diabetes, hypertension, thyroid, or other glandular disorders should be noted. Other illnesses to inquire about: rheumatic fever, diabetes, pneumonia, tuberculosis, arthritis, jaundice, kidney or heart trouble, ulcer, phlebitis, anemia, asthma, hay fever, hives, cancer, measles, adenoviral infections, or pertussis in childhood which may predispose the individual to bronchiectasis. Is the patient taking any medications, such as: antihypertensives, steroids, bronchodilators, heart medications, or diuretics.
• Past Hospitalizations: you also need to document any past hospitalizations for infection or surgery (especially chest procedures which may be the cause of cardiorespiratory insufficiency). Also inquire about dental extractions, upper respiratory tract surgery, or aspiration of foreign bodies, because they may cause pulmonary abscesses.
• Allergies: finally you should ask patients if they have any allergies, for example: to animals, flowers, perfumes, dust, drugs and foods which may trigger allergic reactions.
  Family History: You should inquire about the patient’s familial disease history (particularly hereditary diseases, such as cystic fibrosis and asthma), and illnesses such as TB. You should also determine the patient’s marital status, and the health status of a spouse.

Social and Environmental History: Is the information regarding the patient’s background and living habits that may be associated with the development of illness. Areas where the patient has worked, lived, or traveled should be listed, with the amount of time spent in each area. In addition, your interview should cover the following:

• Patient’s level of education and general economic circumstances
• Military service experience
• Occupational history: Should include the duration of each job. It is important to note exposure to coal dust, asbestos, cloth or wood fibers, or toxic gases. Also, be sure to inquire as the level of stress they feel on the job.
• Activities: Social, religious, hobbies and habits. Do they engage in any hazardous activities? Ask them to describe their general diet, sleeping patterns. Are they having any problems with insomnia? Is adding pillows for sleeping or sleeping in a recliner common? Do they exercise, use tobacco, alcohol, coffee, special drugs (laxatives, sedatives, psychotropics)?
  

   Observation

Observation of the patient, which is the initial phase of the physical examination, actually begins during the interview and needs to be conducted meticulously. Be aware that there will inevitably be some overlap of the information gleaned during the interview, observation, and subsequent hands-on physical examination. All three yield valuable information.

The observation should begin with the caregiver’s glance around the patient’s room that often can tell you a lot about the clinical situation. Some of the more revealing items to look for include the presence of isolation signs and supplies, various monitors or equipment, or chest tubes.

The caregiver should observe the rate, rhythm and frequency of the patient’s respiration during exercise and at rest. It is also important to observe the shape of the patient’s chest, and take note of whether or not the patient needs to use accessory muscles of respiration.

normalities in the formations of the bony thorax and spine (such as kyphosis, pectus excavatum, scoliosis, or lordosis) should also be noted.
It is important to take note the patient’s bed. For example, if the bed is in the Trendelenburg position, it can be suggestive of the existence of hypotension. A bed locked in an upright position or one that has an unusual number of pillows can suggest orthopnea resulting from CHF/pulmonary edema.

The patient’s position in the bed can also be revealing. For example, patients with severe lung disease tend to avoid lying flat in bed because they generally have difficulty breathing in that position.

Many patients who are experiencing excess work of breathing brace their upper torso by resting their arms on the bedside table or holding on to the side rails in order to get increased leverage for the accessory muscles of respiration. Air trapping in COPD patients flattens their diaphragm, so they can frequently be seen in this position because they rely on the upper chest muscles to facilitate breathing.

Observing for Abnormalities

Skin: Observation begins with the skin and mucus membrane color, which indicates oxygenation. If the lips or nail beds have orange, green, or yellow tints, the patient may have impaired liver function. Flushed skin indicates either a fever or high blood pressure. Anemic patients have very pale skin, and diaphoresis (sweating) can be caused by an increase in sympathetic discharge or increased work of breathing
The caregiver should also look for evidence of cyanosis. Cyanosis is a bluish tint of the skin and mucous membranes due to reduced hemoglobin in the subpapillary venous plexus. The amount of reduced hemoglobin depends on the hemoglobin concentration and oxygen saturation. This nonspecific symptom is related to either hypoxemia or decreased perfusion. Detecting cyanosis is often made difficult by available lighting and the patient’s normal skin color. Cyanosis becomes visible to most observers when the amount of reduced hemoglobin in the capillary blood exceed 5 to 6 g/dL. This may be due to a reduction in either arterial or venous oxygen content or both. When the arterial hemoglobin saturation drops to 75% or less, most observers see cyanosis in the mucous membranes of the lips and mouth, as well as the fingers.

Face, Head and Neck: See if the patient’s face is pale or flushed, scarred, swollen, or flabby. Patient distress (respiratory distress, cyanosis, or plethora) can be estimated from facial expressions. Head size, shape, contour, and symmetry are all important to take note of. Also see if there seems to be any tenderness over sinuses or mastoids. Observe any rigidity or limitation of motion in the patient’s neck. Note abnormal pulsation, scars, masses, enlarged salivary glands, or lymph nodes. Describe the thyroid gland, position of trachea, and note carotid and jugular pulses. Jugular venous distension is often due to congestive heart failure, and distention of the jugular veins during expiration can be due to severe obstructive lung disease.

• Ear, Nose, Mouth, and Throat: Check hearing acuity, noting any discharge from the ears, and briefly describe condition of ear drums. Note nasal airway obstructions, septal deviation, discharge, condition of mucosa, and polyps. Check breath odor, color and appearance of lips, tongue, gums condition of teeth, dentures, appearance of mucosa. Describe the palate, uvula, tonsils, and posterior pharynx when indicated, and record findings of examination of nasopharynx and larynx. Check for difficulty with a sore throat, hoarseness, speech defect, difficulty swallowing, or tonsillitis.
• Eyes: Respiratory distress can affect the patient’s pupils. Pupillary size can be affected by cerebral oxygenation, and indirectly by cardiac output.
  Hands and Ankles: Clubbing is a painless, uniform enlargement of the terminal segment of a finger or toe, and is indicative of dilating peripheral vessels and an increase in subcutaneous tissue as a compensatory mechanism for chronic, severe hypoxemia. In this condition a change in the angle between the nail and proximal skin to 180° or greater occurs. In the early stages it’s difficult to diagnose, but in its later stages diagnosis is relatively easy. The normal angle is 160° to 165° for fingers, and 175° for thumbs. Clubbing is said to be present if the hyponychial angle is increased more than 187° to 209°. Ankle edema is important to note because it indicates the possibility of venous return, peripheral vascular disease, fluid overload, and even heart disease.
  

   The Actual Physical Examination of the Patient

Introduction

The patient interview and the caregiver's initial observations yield a great deal of valuable assessment information. The actual physical examination of the pulmonary patient, however, is most valuable to facilitate the caregiver's accurate evaluation of the patient’s condition and subsequent prescription of a treatment protocol.

Vital Signs

One of the most important aspects of the actual “hands-on” physical examination includes checking the patient’s vital signs.

The vital signs are a nonspecific but necessary part of any physical examination, and assessment of the vital signs is the most frequent evaluation technique performed in the clinical setting. The patient’s vital signs provide crucial information and clues regarding the patient’s overall health status, and his/her response to treatments.

Many times during a physical examination, the measuring of the vital signs gives initial evidence of an abnormality. The four basic vital signs are body temperature, pulse rate, blood pressure and respiratory rate. While an in-depth discussion of the vital signs is beyond the scope of this CEU, checking of vital signs should always be considered as part of a patient assessment.

Equipment Needed

• A Stethoscope
• A Blood Pressure Cuff
• A Watch Displaying Seconds
• A Thermometer

General Considerations

• The patient should not have had alcohol, tobacco, caffeine, or performed vigorous exercise within 30 minutes of the exam.
• Ideally the patient should be sitting with feet on the floor and his back supported. The examination room should be quiet and the patient comfortable.
• History of hypertension, slow or rapid pulse, and current medications should always be obtained.

Heartbeat

To begin the assessment of vital signs, the caregiver needs to be adept at taking the patient’s pulse. A pulse indicates a heartbeat and can be felt at any of the patient’s arteries. Documentation of the patient’s pulse should include the frequency, regularity, and quality of the heartbeat. Pulses monitored in adults include the radial, carotid, or femoral pulses. In children and infants, the brachial pulse is preferred. In the documentation process, it is important to note the rate per minute, as well as the regularity and quality of the pulse.

The amount of oxygen being delivered to the patient’s tissues is dependent on the heart’s ability to pump oxygenated blood through the circulatory system. The amount pumped per minute, cardiac output, is a direct function of heart rate and stroke volume. When the oxygen content of arteries dips below normal, often as a result of lung disease, the patient’s heart attempts to maintain normal oxygen delivery by increasing the cardiac output. This is achieved by increasing the heart rate.

The patient’s radial artery is most commonly used to assess the pulse rate. The number of times the heart beats per minute is measured by counting the pulse in the artery. The caregiver places the second and third finger pads on the radial pulse to count for about one minute. Be careful not to hold the patient’s wrist too far above the heart because that can make obtaining an accurate pulse difficult. The normal range for adult heart rates is between 60-100 beats per minute (bpm). The average adult pulse rate is 72/bpm.

A heart rate slower than 60/bpm is called bradycardia, while tachycardia is a rate greater than 100/bpm. A normal pulse beats in consistent intervals, and when the interval varies from beat to beat, the pulse is considered to be irregular.

The pulse rate is influenced by several factors, with exercise being the most obvious. With increased activity, the heartbeat increases 20-30 beats per minute to meet the body’s needs. It should return to normal within 3 minutes after the activity has ceased. The heart rate also increases in response to fear, anxiety, low blood pressure, anemia, fever, hypoxia, and some medications and for many other reasons. Heart rate decreases with hypothermia, certain arrhythmias, certain medications and other reasons.

Remember that spontaneous ventilation can influence pulse strength (amplitude) changes. A significant decrease in pulse amplitude during inhalation is known as pulsus paradoxus (paradoxical pulse). This is common in patients afflicted with obstructive pulmonary disease, particularly those experiencing an acute asthma attack. Pulsus paradoxus also signals the possible existence of mechanical restriction of the heart’s pumping action, such as is seen in constrictive pericarditis or cardiac tamponade. Taking a blood pressure measurement best assesses this condition. An alternating succession of strong and weak pulses, pulsus alternans, suggests left- sided heart failure and is not related to the presence of any respiratory diseases.

Evaluating the carotid, femoral, brachial, temporal, popliteal, posterior tibial, and dorsalis pedis can also assess the patient’s pulse. The carotid and femoral pulse should be used when the blood pressure is abnormally low. To find the carotid pulse, locate the larynx with the tips of your first two or three fingers, slide your fingers away from the larynx (Adam’s apple) toward the groove between the trachea and the large neck muscles, and feel for the pulse. Move your fingertips around until you find the strongest point and feel the pulse. Never use your thumb because it has a pulse of its own and could be mistaken for the patient’s pulse. Count the pulse rate and note whether it is strong, weak, regular or irregular.

If the carotid site is used, you should take care to avoid the carotid sinus area because it can evoke a strong parasympathetic response, causing bradycardia or asystole. To obtain a femoral pulse, visualize the crease between the leg and the abdomen, place the tips of your first two or three fingers at the midpoint, and feel for the pulse.

1. Sit or stand facing your patient.
2. Grasp the patient's wrist with your free (non-watch bearing) hand     (patient's right with your right or patient's left with your left). There is     no reason for the patient's arm to be in an awkward position, just     imagine you're shaking hands.
3. Compress the radial artery with your index and middle fingers.
4. Note whether the pulse is regular or irregular:
    o Regular - evenly spaced beats, may vary slightly with respiration
    o Regularly Irregular - regular pattern overall with "skipped" beats
    o Irregularly Irregular - chaotic, no real pattern, very difficult to        measure rate accurately
5. Count the pulse for 15 seconds and multiply by 4.
6. Count for a full minute if the pulse is irregular.
7. Record the rate and rhythm.

Interpretation

• A normal adult heart rate is between 60 and 100 beats per minute.
  A pulse greater than 100 beats/minute is defined to be tachycardia. Pulse less than 60 beats/minute is defined to be bradycardia. Tachycardia and bradycardia are not necessarily abnormal. Athletes tend to be bradycardic at rest (superior conditioning). Tachycardia is a normal response to stress or exercise.

Blood Pressure

Blood pressure is an indication of how well the heart is pumping, how much blood it pumps, and how efficiently the job is performed. The pressure is the pressure of the blood against the walls of the blood vessels.

The force exerted on the walls of the arteries as blood pulses through them is called the arterial blood pressure. Arterial systolic blood pressure represents the peak force that is exerted during the contraction of the heart’s left ventricle. Diastolic pressure indicates the force that remains after relaxation. Pulse pressure is the variance between systolic and diastolic pressures. For example, if systolic pressure is 120 and diastolic pressure is 100, the pulse pressure is 20. Normal pulse pressure ranges between 35-40 mm Hg. When the pulse pressure measures less than 30 mm Hg, peripheral pulse is difficult to detect.

On the other hand, the patient’s blood pressure is determined by: the force of the left ventricular contraction, the systemic vascular resistance, and the blood volume. Normal systolic pressure ranges from 95-140 mm Hg, with an average of about 120 mm Hg. Normal diastolic pressure ranges from about 60-90 mm Hg, with the average norm being 80 mm Hg. Blood pressure is recorded as a fractio