1
Q
patient examination
A
Look at your patient:
- comfortable? facial expression?
- posture, shape of chest?
- extremities: hairy? scars?
- fingers: clubbing?
Vital signs
Breath/lung, heart, voice sounds
2
Q
Vital sounds
A
“signs of life”
measures taken to assess the most basic body functions
1: Heart rate
2: Respiratory rate
3: Blood pressure
4: Temperature
5: Pain
6: Gait speed
3
Q
normal resting heart rate
A
60-100 bpm
4
Q
bradycardia
A
resting <60 bpm
5
Q
tachycardia
A
resting >100 bpm
6
Q
HR locations
A
Carotid Brachial Radial Femoral Popliteal Tibial Dorsal Pedis
7
Q
HR response to exercise
A
normal: HR increases proportionally to workload (~10 bpm per MET (unless on beta blocker))
HR returns to baseline following 2 minutes of rest
8
Q
abnormal HR response to exercise
A
flat/blunted: little/no increase
Bradycardic: >10 bpm drop (severe CAD)
Tachycardic: excess rise (deconditioned, dehydrated, decreased SV)
sudden change >20-40 bpm for >3 minutes at rest, during activity, or following a change in position (refer to MD)
9
Q
factors affecting HR
A
aging anemia autonomic dysfunction caffeine cardiac muscle dysfunction drugs fear fever hyperthyroidism infection pain sleep disturbances emotions
10
Q
pulse rhythm
A
Regular
Irregular
- regularly irregular (usually AFIB-pre beat or skips a beat)
- irregularly irregular (can only take an average for HR)
11
Q
pulse strength
A
- indication of circulating blood volume and strength of LV ejection
- increases slightly with inspiration and decreases with expiration
- Paradoxic= amplitude fades with inspiration and strengthens with expiration (notify MD- occurs with COPD)
12
Q
pulse strength grades
A
0= absent 1=weak 2=normal 3= full 4= aneurismal/bounding
13
Q
tips for taking HR
A
- check in 2 places in older adults and those with DM (pulse diminishes with age- esp distally)
- if diminished or absent, listen for bruit (indicates narrowing)
14
Q
RPE
A
rate of perceived exertion, measures total feeling of exertion and fatigue
alternative tool to measure exercise intensity. useful for patients whose HR is affected with meds
15
Q
inspiratory muscles
A
diaphragm
external intercostals
interchondrial intercostals
accessory: scales/SCM
16
Q
expiratory muscles
A
abdominals
internal intercostals
17
Q
lung compliance
A
- related to elasticity of tissues. measured by pressure-volume curve
- decreases: lungs become stiffer and more difficult to expand.
- increases: lungs become easier to distend and more compliant
chest wall compliance and lung compliance can change lung volumes
18
Q
ventilation
A
=movement of oxygen in and out of lungs
19
Q
factors affecting ventilation
A
chest wall mechanics:
- kyphosis
- scoliosis
- posture
- hyperinflation
- arthritis
pulmonary mechanics:
- airway inflammation, constriction, degeneration
- increased dead space (scar tissue, emphysema)
- ventilation/perfusion
gas exchange mechanics
- pulmonary HTN
- pulmonary edema
- CHF
20
Q
normal respiration rate
A
12-20 bpm
increase in rate and depth proportional to workload
max RR achievable with exercise ~50 bpm
21
Q
respiration rate precaution
A
> 35 with exercise
22
Q
respiration rate contraindication
A
> 45 to exercise
23
Q
assessing RR
A
can use talk test and/or dyspnea index
minute ventilation= RR x TV
24
Q
factors affecting RR
A
changes in lung compliance
airway resistance
body position
changes in lung volumes and/or lung capacity
25
tips for taking RR
- take right after HR while still holding wrist
- if unlabored and regular, take for 30s X 2
Observe:
- rate, excursion, effort and pattern
- accessory ms.
- breathing: silent/noisy
- puffed cheeks, pursed lips, nasal flaring, asymmetrical chest expansion
26
chest breather
?
27
diaphragmatic breather
- SOB
| - helps to be more conscious of breathing
28
pulse oximetry
=measures arterial oxygen saturation (SaO2) and pulse simultaneously
normal= >95%
don't exercise: <85%
29
false pulse oximetry
```
nail polish
acrylic nails
chemotherapy
anemia
cold skin
```
30
normal systolic BP with exercise
=7-10 mmHg/MET
31
abnormal SBP with exercise
HYPOTENSIVE: decreases 10-20mmHg with increased workload
FLAT/BLUNTED: little/no increase
HYPERTENSIVE: excess increase
(should never increase >225 mmHG)
32
normal diastolic BP with exercise
=little/no change with aerobic exercise
| no more +/- 10 mmHg
33
abnormal DBP with exercise
HYPOTENSIVE: decrease >10 mmHg below resting
| HYPERTENSIVE: increase 15-20 mmHg
should not exceed 120 mmHg
34
pulse pressure
=SBP - DBP
normal= >20
increases with age and with exercise
low PP indicates low CO in adults with acute heart failure.
increased PP indicates vascular wall stiffness and predicts heart failure in HTN patients
35
factors affecting BP
```
age
blood vessel size
blood viscosity
force of heart contraction
meds
diet
distended bladder
time of recent meal
caffeine
nicotine
alcohol
anxiety
pain
high altitudes
```
36
yellow flags for BP
- DBP 75 y/o
- persistent rise/drop in BP over 2 weeks
- steady fall over several years >75 y/o
- lower SBP (65 w/ fall hx
- PP difference >40
- difference >10 from side to side
- BP changes w/ other signs (dizzy, nausea, extreme sweating
- sudden drop in SBP (>10-15) or DBP (>10) with 10-20% rise in HR- ORTHOSTATIC HYPOTENSION
37
normal temperature
98.7 F
37 C
fever= >100.4
38
temp can vary by:
- age
- person
- time of day
- where taken on body
39
elevated temps caused by:
```
being active
being in high temps
eating
feeling strong emotions
menstruating
certain meds
teething
heavy clothing
```
40
gait speed
walking speed has been related to dependence, hospitalization, rehab needs, discharge location, mortality
6 minute walk test
3 minute step test
41
abdominal exam
inspect
auscultate
percuss
palpate (painful area last)
assess each quadrant:
- check for rebound tenderness
- check for masses
- check for muscle guarding
- check for bounding pulse
42
BMI
weight (kg) divided by height (m) squared
underweight 30
43
normal heart sounds
S1
| S2
44
S1 heart sounds
"lub"
mitral and tricuspid valves closing at onset of ventricular systole (muscular contraction phase of cardiac cycle- begins at end of diastole)
45
S2 heart sounds
"dub"
| aortic and pulmonic valves closing at onset of diastole (period of relaxation and filling)
46
abnormal heart sounds
S3
| S4
47
S3 heart sound
"ventricular gallop"
associated with early rapid passive filling of the ventricles immediately after the MV and TV open.
most frequently associated with heart failure but may occur in children and young adults up to age 40.
abnormal in older adults; noncompliant LV, maybe associated with CHF
48
S4 heart sound
"atrial gallop"
pathological sound of vibration of ventricular filling
associated with HTN, stenosis, hypertensive heart disease or MI
"atrial kick" indicates elevated atrial pressure
49
murmurs
due to turbulent blood flow; usually heard as a "whooshing" sound
can be normal or pathological
50
3 categories of murmurs
1: caused by high rates of flow through normal or abnormal valves
2: caused by forward flow through a stenotic or deformed valve
3: caused by backward flow though a valve (regurgitation)
51
examine the chest
```
observe body type
overall posture
chest type
look for symmetry
coloration
scars
abnormal movements
muscle contraction
```
52
rib flares
trying to expand lung
53
Schamroth's sign
indicates clubbing
schamroth's window
54
intercostal indrawing
because breathing is so tough
intercostal spaces are drawn inwards on inspiration- especially with inspiratory effort
seen in patients with severe obstructive disease
55
sign of respiratory problems
"BAD CAT"
Breathing that is audible
Active accessory muscles
Dyspnea
Cyanosis/ clubbing
Anterior/posterior diameter >1
Tracheal deviation from midline
56
eupnea
normal respiratory rhythm
normal: expiration twice as long as inspiration
57
dyspnea
labored or difficult breathing (usually associated with lung or heart disease and resulting in SOB
58
hyperpnea
breathing that is regulated to meet an increase demand by the body for oxygen
59
apnea
temporary cessation of breathing at the end of normal expiration
60
apneusis
sustained, gasping inspiration followed by short, inefficient expiration which can continue to the point of asphyxia
associated with lesions in the respiratory center in the brain
cessation of breathing in the inspiratory phase
61
respiratory arrest
failure to resume breathing following a period of apnea or apneusis
62
cheyne strokes respiration
periodic type of abnormal breathing often seen in terminally ill or brain damaged patients.
63
biot's breathing
characterized by repeated sequences of deep gasps and apnea
64
assessing depth and symmetry of movement
seated
normal findings: 3-5 cm expansion
positive findings:
- <3 cm movement
- unilateral delay suggests atelectasis, pneumonia, and post op guarding
65
measuring thoracic excursion
standing, T5 and T10
instruct pt to take full inspiration and hold; fully exhales and holds
normal:
- upper chest 3.6 cm (+/- 0.6)
- lower chest 4.9 cm (+/- 0.6)
positive findings: <1.7 cm
66
breath sounds
generated by the vibration and turbulence of air flowing in and out of the airways and lung tissue during inhalation and exhalation
67
4 normal breath sounds
1: tracheal
2: bronchial
3: vesicular
4: bronchovesicular
68
tracheal breath sounds
high pitched and loud heard over trachea alone
| ~wind blowing through a pipe
69
bronchial breath sounds
heard adjacent to the sternum and over major airways
similar to tracheal sounds but not as loud
louder on expiration than inspiration
when heard in other areas, are abnormal
-may be due to consolidated, compressed or airless tissue
70
vesicular breath sounds
- low pitched and muffled
- inspiration is louder, longer and higher pitched than expiration (very brief)
- normal in all areas of lung except over trachea
71
bronchovesicular breath sounds
inspiration/expiration are similar lengths at the same pitch with a slight break between the two
normal when heard adjacent to sternum at costo-sternal border or between scapulae at T3-T6
72
normal lung sounds
have pt do at least 1 full breath when listening to each area
4 spots anteriorly
14 posteriorly
73
5 abnormal lung sounds
1: bronchial
2: vesicular
3: fine crackles
4: wheezing/Rhonchi
5: coarse crackle
74
abnormal bronchial lung sounds
when heard at a distance from large airways, it is considered abnormal
most likely indicated a consolidated lung
75
vesicular lung sounds
- sound heard over the chest at a distance from large airways
- "soft" soft that has been compared to the sound of wind blowing through the leaves of a tree
- longer inspiration than expiration
- most common sound heard in the absence of lung disease
76
fine crackle lung sounds
"discontinuous" intermittent, "explosive" sounds
high pitched, popping sound of airways opening
heard in atelectasis, interstitial pulmonary fibrosis and sometimes in healthy people
77
wheezing/ rhonchi
continuous high, medium or low pitched whistling sounds
caused by airway narrowing (bronchospasms), secretions
heard on either inspiration or expiration or both
expiratory more common- associated with diffuse airway obstruction- CF, chronic bronchitis, asthma
78
coarse crackle lung sounds
intermittent "bubbling" sound
caused by secretions in airways
not as high pitched as fine crackles
79
voice sounds
used in examination of the chest to determine the presence/absence of consolidation (pneumonia, cancer, hemothorax, something dense filling the airspace)
1: egophony
2: bronchophony
3: whispered pectoriloquy
4: fremitus
80
egophony
- listen to chest with stethoscope all along different lobes
- patient says the letter "E"
normal: sounds like muffled long E sound
presence of consolidation (pneumonia, cancer) will hear a higher pitched sound like "A"
"E to A changes"
81
bronchophony
- listen to stethoscope to symmetrical areas of the patient's lungs
- asks patients to repeat a work (99, 66)
normal: sound becomes less distinct (quieter) as move to periphery of lungs; muffled, indistinct sounds
presence of consolidation: voice remains loud or becomes louder in periphery; 99 sounds normal
may be noted as "increased breath sounds"
82
whispered pectoriloquy
refers to the loudness of a whispered voice while listening to the lungs with a stethoscope
-ask pt to whisper "1,2,3" repeatedly
normal: whispered sounds would be faint or not heard
presence of consolidation: they are heard
83
voice fremitus
- vocal or tactile fremitus is the vibration produced by the voice and transmitted to the chest wall
- PT evaluated fremitus by comparing the intensity of the vibrations detected by each hand during quiet breathing and speech
normal: equal and moderate vibrations are noticed during speech
increased: indicates a loss or decrease in ventilation in the underlying lung
decreased: indicates increased air within the lung bc sound is similarly transmitted more poorly through a hyper-inflated lung
84
tactile fremitus
pt seated
-place ulnar hand over posterior thorax between SP and scapula
pt repeats "99" and PT notes bilateral differences
repeat on anterior chest at supraclavicular area, lateral to sternum below T4
85
percussion
?
86
6 MWT
submax tests
better reflects function activities/ADLs
used to assess: pts who have heart and lung disease, functional status, and predictor of mortality and morbidity
does not replace cardiopulm exercise testing, stress testing or VO2 max testing (complementary test)
87
patient preparation
- comfortable clothing should be worn
- appropriate shoes for walking should be worn
- patients should use usual walking aids
- pt's medical regimen should be continued
- a light meal is acceptable before
- pts should not have exercised vigorously w/in 2 hours before test
* *pt should sit at rest in a chair, located near the start, for at least 10 min before the test starts. during this time, check for contraindications, measure pulse and BP, and make sure that clothing and shoes are appropriate.
- pulse oximetry
- Borg scale
- pt rate their baseline dyspnea and overall fatigue using the Borg scale
88
object of the 6 MWT
to walk as far as possible for 6 minutes. you will probably get out of breath or become exhausted. you are permitted to slow down, stop and rest as necessary.
*to walk AS FAR AS POSSIBLE for 6 min, but don't run or jog
89
3 step protocol
step height= 16.25"
step for 3 minutes
females: 22 complete step ups per min (88bpm metronome)
males: 24 complete step ups per min (96 bpm metronome)
take pulse for 30s immediately after test and multiple by 2
90
can't clear airway, susceptible to:
- obstruction (due to heavy secretions)
- inflammation
- infection
- atelectasis
- abnormal ventilation/perfusion relationships
- deterioration of arterial blood gas values
Cardiopulm 2
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