Respiratory AssessmentR. HernandezChest Physical Assessment• Inspection• Palpation• Percussion• AuscultationInspection• Level of Conciousness• Evidence of Respiratory disease– Nasal flaring– Cyanosis• Peripheral – Circulation• Central - Hypoxemia– Pursed-lip breathingInspection• Jugular Neck Vein Distention• Head of bed 45 degrees–Normal• <3-4 cm above sternalangle– Increased– Markedly increased• Use of Accessory muscles• Enlarged lymphInspection–Thorax– Observe for retractions and use of accessory muscles (sternomastoids, abdominals). – Retractions– Observe the chest for asymmetry, deformity, or increased anterior-posterior (AP) diameter.– Confirm that the trachea is near the midline?http://www.meddean.luc.edu//lumen/MedEd/medicine/pulmonar/pd/pstep25a.htmInspection• Pectus Carinatum• Pectus Excavatum• Kyphosis– Anteroposterios• Scoliosis - LateralInspection• Increased A-P DiameterChest Physical Assessment• Inspection• Palpation• Percussion• AuscultationPalpation•Tracheahttp://www.meddean.luc.edu//lumen/MedEd/medicine/pulmonar/pd/pstep25a.htm• Chest– Repeat ninety-nine– Increased• Consolidation– Decreased• Obstruction• Increase air - fluidPalpation• Thoracic Expansion• Normal Movement–3-5 cm• Assess expansion and symmetry of the chest by placing your hands on the patient's back, thumbs together at the midline, and ask them to breath deeplyhttp://www.meddean.luc.edu//lumen/MedEd/medicine/pulmonar/pd/pstep26a.htmPalpation• Peripheral Edema•+1 -+4Chest Physical Assessment• Inspection• Palpation• Percussion• AuscultationPercussion• Hyperextend the middle finger of one hand and place the distal interphalangeal joint firmly against the patient's chest. • With the end (not the pad) of the opposite middle finger, use a quick flick of the wrist to strike first finger. • Categorize what you hear as normal, dull, or hyperresonant. • Practice your technique until you can consistantly produce a "normal" percussion note on your (presumably normal) partner before you work with patients.PercussionPosterior Chest• Percuss from side to side and top to bottom using the pattern shown in the illustration. Omit the areas covered by the scapulae. • Compare one side to the other looking for asymmetry. • Note the location and quality of the percussion sounds you hear. • Find the level of the diaphragmatic dullness on both sides.Percussion• Diaphragmatic Excursion• Find the level of the diaphragmatic dullness on both sides. • Ask the patient to inspire deeply. • The level of dullness (diaphragmatic excursion) should go down 3-5cm symmetrically.PercussionAnterior Chest• Percuss from side to side and top to bottom using the pattern shown in the illustration. • Compare one side to the other looking for asymmetry. • Note the location and quality of the percussion sounds you hear.Percussion• Percussion Notes and Their Meaning• Flat or Dull– Pleural Effusion or Lobar Pneumonia• Normal– Healthy Lung or Bronchitis• Hyperresonant– Emphysema or PneumothoraxChest Physical Assessment• Inspection• Palpation• Percussion• AuscultationStethoscope• Chest piece– Diaphragm• High frequency - Lungs–Bell• Low frequency – Heart• Tubing– 11-16 inches• Ear pieces–Angled• Low level disinfection between patient useChest SegmentsAnterior PosteriorNormal Breath Sounds• Inhalation / Exhalation• Upstroke / Downstroke• Length– Duration• Thickness of Stroke– Intensity• Angle–PitchNormal Breath Sounds• Vesicular– Low Pitch, Soft Intensity– Peripheral lung areas• Bronchovesicular– Moderate Pitch, Moderate Intensity– Medial Chest• Bronchial– High Pitch, Loud Intensity– TracheaAdventitious Breath Sounds• Crackles– Discontinuous, secretions, atelectasis• Wheezes– High Pitched– Obstruction, anatomic, bronchoconstriction, inflammation• Stridor– High pitchedLocalization of Adventitious BS• Location•When– Inspiratory / Expiratory•Pitch• Prominance / Loudness– Increased /