Section I.  B.  Collect and Evaluate Additional Pertinent Clinical Information

 

1. Inspection

 

  This should be performed with the patient seated and clothing removed above the waist in order to inspect the chest. If the patient can’t sit up in a chair he or she should be placed in bed in the folwers position.

 

Inspection (CHEST) should include rate, depth and regularity of a patient breathing compared with the norms. Skin color, temperature, and general condition of the skin. Chest symmetry. Look for equal expansion and non-equal expansion of the chest. Unequal expansion may mean atelectasis, pneumothorax, or chest deformities.  Inspection should include observing the shape of the chest as well. Observe the AP Diameter of the chest (increased AP diameter= barrel chest) Observe Patients work of breathing. Are accessory muscles being used?  Is expiration prolonged? Are there retractions present? 

 

Chest deformities are:

 Kyphosis backward curvature of the spine- hunchback

Lordosis is backward curvature of the spine- swayback

Scoliosis is lateral curvature of the thoracic spine resulting in chest protrusion

Kyphoscoliosis is combination of kyphosis and scoliosis.

Pectus Carinatum forward projection of the xiphoid process and lower sternum. Congenital condition- pigeon chest.

Pectus excavatum is usually a congenital condition. Also called funnel chest.

Barrel Chest is caused by premature closure of the airways that causes trapping of the air and hyperinflated lungs giving the chest a barrel shape.

 

*Cardiopulmonary problems don’t usually show up until patients are in the 40-50 range.

 

Inspection (Extremities)-Look for digital clubbing (result of chronic hypoxemia).  Look for pedal edema. (Accumulation of fluid in the subcutaneous tissues.) This results in increased workload on the right heart, right ventricular hypertrophy and eventually cor pulmonale. Look for cyanosis in the finger beds. (Bluish discoloration of the skin and nail beds. Cyanosis may indicate decreased oxygenation or reduced peripheral circulation.

 

 

2. Palpation

 

Using the sense of touch on the chest wall to Assess physical signs. Ands are place don the chest to assess chest moved and vibration.

 

Tactile Fremitus are vibrations felt on the chest wall as the patient speaks. They originate in the vocal cord and are transmitted down the trachebronchial tree. Vibrations are decreased under pleural effusions, fluid and pneumothorax. Vibrations are increased over atelectasis, pneumonia, and lung masses.

 

Assess for position of trachea.

 

Asses by placing both thumbs on each side of the suprasternal notch and gently pressing inward. Only soft tissue should be palpable. If the trachea is felt, it indicates that the trachea has shifted and is no longer position midline. A shift in the trachea position may be result of a tension pneumo or massive atelectasis.

 

Tension Pneumo: trachea shifts to the unaffected side (opposite pneumo.)

Atelectasis: trachea shifts toward the affected side (same as atelectasis)

 

 

3. Auscultation

 

Normal Breath Sounds (vesicular) gentle rushing sound heard over the entire chest wall. Inspiration is longer than expiration with no pause between.

 

Bronchial Breath Sounds are loud and generally high-pitched sounds heard over the upper portion of the sternum, trachea and both main stem bronchi. Expiration is longer than inspiration with a short pause. If hared in other lung areas this indicates consolidation or atelectasis.

 

Bronchovesicular Breath Sounds are a combination of bronchial and vesicular breath sounds, normally heard over the sternum, between the scapulae and over the right apex of the lung. Inspiration and expiration are of equal duration with no pause.

 

Tracheal Breath sounds are harsh and high-pitched sounds heard over trachea. Expiration is slightly longer than inspiration.

 

 

Adventitious Breath Sounds:

 

Crackles are bubbling or crackling sound heard primarily on inspiration produced by air flowing through fluid in the alveoli or small airways. Crackles are commonly heard in patients with pulmonary edema, pneumonia, emphysema, atelectasis, or fibrosis. Crackles are also heard on the end of inspiration resulting from alveoli popping open.

 

Rhonci are sounds that are produced in the airways filled with secretions or fluids. Typically a rumbling sound is heard on expiration. In larger airways. Suction indicated. Caused by asthma, emphysema mucus plugs or stenosis.

 

*Rhonci usually clear after coughing, crackles usually do not.

 

 

Wheezes are often considered a rhonci with a musical effect. These are produced by airflow through constricted airways. May be heard on both inspiration and expiration. Characteristic of Asthma and are a result of bronchoconstrction.

 

Normal Heart Sounds are thought to be produced as a result of sudden changes in blood flow through the heart that cause a Vibration of the valves and chambers inside the heart. The normal heart sound is a “lubb-dubb”

 

“Lubb” closing of the AV valve. The av valves are the mitral valve (Left atrium and left ventricle) and the tricuspid (between the right atrium and the right ventricle) the first heart sound is noted as S1.

 

 

“Dub” is the second heart sound.  This represents the closing of the semi lunar valves. These valves consist of the pulmonic valve (between the right ventricle and the pulmonary) and the aortic valve (between the left ventricle and aorta. This sound is known as S2

 

There are also S3 and S4 sounds that are abnormal. These heart sounds are more difficult to hear than S1 and S2.

 

S3 is to result from blood rushing into the ventricles during early ventricular diastole.

S4 results from the atrial contraction.

 

 

Murmurs:  These occur when blood flows in a turbulent fashion through the heart structures that have a decreased cross-sectional area.  Murmurs described by the location of the sound, the part of the cardiac cycle they occur in and the intensity of the sound.

 

Blood Pressure is a measurement of the pressure within the arterial system. Normal range for adults is 140/80. Systolic pressure is the pressure during ventricular contraction. Diastolic pressure is measured while the ventricles are at rest. Hypotension (low BP) is caused by blood loss, positing and CNS depressant drugs. Hypertension (Hi BP) is caused by cardiovascular imbalances, stimulant drugs, stress and fluid retention. Things like blood volume, blood viscosity and hearts pumping action all affect BP. BP is measured with a sphygmomanometer.

 

4. Interview

 

First decide if the patient is alert and oriented to date and time. Assess sedation and consciousness. Assess if the information the patient is giving you is valid or if you need to retrieve it from a secondhand source. Assess level of cooperation and emotional state.

 

Interview the patient for subjective material. These would be words describing how the patient seems to feel. Does the patient feel short of breath? Is it all the time, or while walking? Lying down?  Do they cough a lot? If so do they cough anything up? What color is it?  What kind of exercise do they do? Everyday? How well can they withstand doing exercise?  

 

Interview for H and P. (history and physical) Do they smoke? Smoking history? Family history. Etc

 

DNR Status?

 

 

5. Assess Learning Needs

 

Decide whether the patient is able to give you correct and valid information from. Is the patient alert, obtunded, lethargic, or in a coma?

 

 

6. Review Patient Chest Radiograph

 

 

It is very important to first confirm that the x-ray is valid and that the quality of the x-ray is good. Is the positioning of the patient good enough?

 

On x-rays you can decipher whether or not the position of an endotracheal tube is in the proper positions. By looking at the x-ray you can see that the ET Tube should rest about 2-7 cm above the carina. On an x-ray it should be located at the level of the fourth rib or the fourth thoracic vertebra. If the ET tube is inserted too far it will most likely enter the right main stem bronchus.

 

Atelectasis on an x-ray appears lighter than normal lung disease. It may indicate y elevated diaphragm, mediastinal shift (toward affected area) or increased density and decreased volume of lung area.

 

Pneumonia appears white on the x-ray. Consolidation of entire lobe or more may cause mediastinal shift toward the consolidation.

 

Pneumonthorax is air found in the pleural cavity. It appears dark with no vascular markings in the involved area.  

 

Tension Pneumothorax may result in mediastinal shift and the tracheal shift away from the side of the pneumo.

 

Diaphragm should be rounded or dome shaped. It appears white on the x-ray film at the level of the 6th rib. Patients with Hyperinflated lungs have flattened diaphragms. Both hemidiaphragms should be assessed for height and angle to the chest wall. The dome of the right hemidiaphragm is normally 1 to 2 cm higher than the left (because of the liver) Elevation of one hemidaphragm may be the result of gas in the stomach or atelectasis.

 

You may also see on an x-ray if there is a foreign body obstruction. On a CXR you may see hyperinflation of the affected lung. Mediastinal shift away form the side of the aspiration during expiration as the affected lung becomes hyperinflated.