CHAPTER 3 ASSESSMENT OF THE CARDIOPULMONARY PATIENT
PRETEST QUESTIONS
1. A patient coughs up yellow sputum after an IPPB treatment. Which one of the following statements is TRUE in regard to this sputum production?
2. The term used to describe a condition in which a patient has difficulty breathing while in a supine position is which of the following?
3. A patient enters the emergency department, and on initial examination the respiratory therapist observes paradoxical chest movement. Which of the following should the practitioner suspect?
4. Perfusion in the extremities may best be determined by which of the following methods?
5. While palpating the chest, the respiratory therapist determines that there are decreased vibrations over the right lower lobe. This may be the result of which of the following?
6. A chest x-ray film obtained after ET intubation shows the tip of the ET tube is resting at the fourth rib. Which of the following actions should be taken?
7. A patient is suspected of having intrathoracic metastatic nodal disease. Which of the following imaging studies should the respiratory therapist recommend to determine, with the highest accuracy, whether disease is present?
8. Which of the following imaging studies may be useful in determining whether a pulmonary embolism is present?
REVIEW
CRT Exam Content Matrix: IA1, IB5a-f
1. Introduce yourself and establish a rapport with the patient so that the patient feels comfortable and open to discussion.
2. Try to avoid leading questions, such as “Are you still short of breath?” These questions may elicit a different response than would “How is your breathing at this time?”
4. Promote a relaxed atmosphere and avoid difficult medical terms that the patient may not understand.
CRT Exam Content Matrix: IA2, IB1c, IB5a-f, IIIE5a
RRT Exam Content Matrix: IA2, IB1c, IB5a-e
Foul-smelling sputum that often settles into several layers is characteristic of bronchiectasis. (See Chapter 12 on disorders of the respiratory system.)
c. When a cough is productive, it is important to record the amount, consistency, odor, and color of sputum because changes in these qualities over 24 h are important in the diagnosis of pulmonary disease.
Exam Note(5) Frequent hacking cough and throat clearing may be the result of smoking or sinus or viral infection.
a. It is a subjective symptom, meaning the patient expresses breathing difficulty, and can be influenced by the patient’s reactions and emotional state.
Exam Note(1) Orthopnea is dyspnea while lying down. The condition is usually seen in patients with heart failure and is caused by increased congestion of the lungs while lying down. It is often observed in patients with emphysema because of their inadequate diaphragmatic movement during ventilation.
(2) Paroxysmal nocturnal dyspnea is sudden onset of shortness of breath after being in bed for several hours. It is seen in cardiac patients and results in acute pulmonary edema, which usually subsides quickly after the patient is positioned upright.
(3) Exertional dyspnea is often seen in patients with cardiopulmonary disease. The severity is determined by the amount of exertion. It is important to determine at what point the patient experiences dyspnea: Does it begin after walking up a flight of stairs or after simply walking across the room?
b. Hemoptysis is determined by the coughing up of a certain volume of blood; the amount indicates the severity of the symptom.
d. Patients may think they are “coughing up blood” from the lungs when the blood is from the gastrointestinal tract. The origin of the blood must be determined.
d. The parietal pleura (layer lining the chest wall) is very sensitive to pain and is usually the source of pain associated with pneumonias, pleurisy, and other inflammatory processes.
e. Chest pain may be associated with pulmonary hypertension caused by the increased tension on the walls of the vessels and increased workload on the right side of the heart.
f. Chest pain may originate from the heart as a result of an inadequate blood supply. This pain is called angina pectoris.
g. Chest pain is also associated with a ruptured aorta, myocardial infarction, and esophageal problems.
III. OTHER PHYSICAL ASSESSMENTS
RRT Exam Content Matrix: IA2, IA6, IA8a-b, IB1a, IB2a-b, IB4a-c, IB7a-e, IB8, IC2, IIIA1b3, IIIE1
2. Bradypnea: less than the normal respiratory rate. May be seen with respiratory center depression caused by head trauma or drug overdose.
3. Apnea: absence of breathing for a specific period of time (usually at least 10 s). Seen in patients with respiratory arrest caused by asphyxia, severe drug overdose, central and obstructive sleep apnea, and other central respiratory center disorders.
4. Tachypnea: faster than the normal respiratory rate but with the normal depth of breathing. May indicate decreased lung compliance and is associated with restrictive diseases, pneumonia, and pulmonary edema.
5. Hypopnea: shallow respirations (about half of normal depth) with slower than normal respiratory rate. Hypopnea is normal in well-conditioned athletes and is accompanied by a slow pulse rate. May be seen in patients with damage to the brainstem and is accompanied by a weak, rapid pulse.
6. Hyperpnea: deep, rapid, and labored breathing. Associated with conditions in which there is an inadequate oxygen supply, such as cardiac and respiratory diseases. Usually refers to hyperventilation.
7. Kussmaul respiration: increased rate and depth of breathing. Usually seen in patients with severe metabolic acidosis (diabetic ketoacidosis).
8. Biot respiration: irregular breathing pattern characterized by short periods of deep, consistent volumes with periods of apnea. The apneic period may last 10 to 30 s. Associated with elevated ICP or meningitis.
9. Cheyne-Stokes respiration: deep, rapid breathing followed by apnea. The breaths begin slow and shallow and gradually increase to above normal volume and rate, then gradually diminish in volume and rate, followed by apnea. Apnea may last 10 to 20 s before the cycle is repeated. Seen with respiratory center depression caused by stroke or head injury, pneumonia in the elderly, congestive heart failure, or drug overdose.
B. Chest Inspection: This should be performed with the patient seated and with clothing removed above the waist. If the patient is not able to sit in a chair, he or she should be placed in bed in Fowler position (i.e., head of bed elevated 45 degrees). Inspection should include
1. The rate, depth, and regularity of breathing compared with the norms for the patient’s age and activity level.
2. Skin color, temperature, and condition, such as bruises or scars. Is the patient diaphoretic (perspiring)?
a. Observe chest excursion while standing in front of the patient to determine whether both sides are expanding equally.
(4) Flail chest: “Paradoxical” respirations may be observed, in which the chest moves in on inspiration and out on expiration. Flail chest is the result of chest trauma, a fractured sternum, or fractured ribs.
The intercostal muscles and diaphragm are the major muscles for normal ventilation. The accessory muscles are the scalene and the sternomastoid muscles in the neck and the pectoralis major muscle in the anterior chest. When accessory muscles are used during ventilation, it is a sign of respiratory distress.(9) Are substernal, suprasternal, or intercostal retractions or nasal flaring observed? These are all signs of respiratory distress.
a. Digital clubbing is indicative of long-standing pulmonary disease: 75% to 85% of all clubbing is the result of pulmonary disease.
b. Consists of enlargement of the distal phalanges of the fingers and, less commonly, the toes. There is a loss of the angle between the nail and dorsum of the terminal phalanx.
b. This symptom is commonly observed in patients with chronic pulmonary disease, in which their chronic hypoxemic state results in pulmonary vasoconstriction.
c. The right side of the heart works harder as it pumps blood through narrowed pulmonary vessels, which results in an increased workload on the right side of the heart, right ventricular hypertrophy, and, eventually, right-sided heart failure (cor pulmonale).
d. As right-sided heart pressures increase, venous blood flow returning to the heart is diminished, and the peripheral blood vessels become engorged. The ankles are most affected as a result of gravity. This is often accompanied by jugular venous distention (JVD). The jugular veins returning blood from the upper body also become engorged as a result of elevated pressure in the right side of the heart.
a. Refers to the bluish discoloration of the skin and nailbeds resulting from a 5 g/dL decrease in oxygenated Hb. For example, a patient with an Hb level of 15 g/dL would have cyanosis if the oxygen saturation dropped to a level where only 10 g/dL was saturated with oxygen.
c. Patients with decreased Hb levels (anemia) may not exhibit cyanosis even if tissue hypoxia is present. An anemic patient has a low oxygen-carrying capacity, which may result in tissue hypoxia but does not cause cyanosis unless 5 g/dL of unsaturated Hb is present. If there is not enough Hb in the blood to manifest it, cyanosis will not occur.
d. Conversely, a patient with an increased level of Hb (polycythemia) has an increased capacity for carrying oxygen. This patient may have a level of 5 g/dL of unsaturated Hb and therefore may have cyanosis yet have enough saturated Hb to adequately oxygenate the tissues.
b. This is performed by compressing the patient’s fingernail for a short time, then releasing it and observing the time it takes for blood flow to return to the nailbed.
a. Concave curvature of the spine, resulting in a “hunchback” appearance. It is best assessed from an anterior view.
a. Lateral curvature of the thoracic spine, resulting in chest protrusion posteriorly and the anterior ribs flattening out. Chest protrudes on right or left side.
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