Assessment of The Patient

Assessment of The
Patient
210a
Objectives
• List The Elements of an Effective And
Thorough Bedside Interview
• List The Factors That Influence

Communication Positively And Negatively
• Define The Difference Between Objective

And Subjective Data
Objectives
• List The Causes of Cough, Sputum
Production, Hemoptysis, Dyspnea, Chest
Pain, Swelling of Feet And Ankles, Fever,
Altered Mental Status, And Dizziness
• Identify Normal And Abnormal Breathing

Patterns
1
Objectives
• Identify Normal And Abnormal Breath
Sounds
• List The Normal Values of a CBC
• List The Normal Values of a Chemistry

Panel And The Causes of Deviations From
The Normal Values
Objectives
• List The Common Normal Flora Found
During Culture
• List The Pathogens Found During Culture
• List The Normal Values For an Arterial

Blood Gas
Objectives
• List The Indications For Chest Radiography
• List The Common Views And The

Indications For Each
• List The Normal Parts of an ECG Wave
2
Objectives
• List The Abnormalities of an ECG And
Significance of Each
• Explain The Need for Nutritional

Assessment
Introduction
• Clinical assessments helps physicians
make decisions regarding when to initiate,
change, or discontinue therapy depend
upon accurate.
• Physician is responsible, but RTs
participate in clinical decision making
• Bedside assessment:
– Process of interviewing and examining
patient for signs and symptoms of disease
– Evaluating the effects of treatment
Introduction (Cont.)
• Inexpensive and little risk to patient
• Part of initial assessment to identify
diagnosis and to evaluate ongoing effects
of treatment
• Data gathered during the initial interview
and physical examination help identify the
need for subsequent diagnostic tests
• Two key sources of patient data:
– Medical history
– Physical examination
3
• Patient initially is assessed to identify the correct
diagnosis
• Diagnosis is the process of identifying the nature
and cause of illness
• Differential diagnosis is the term used when
signs and symptoms are shared by many
diseases and the exact cause is unclear
• Signs refer to the objective manifestation of
illness
• Symptoms refer the sensation or subjective
experience of some aspect of an illness
10
Where can we find this information? Chart Review
• Demographic Data
• Chief Complaint (CC)
• History of Present Illness (HPI)
• Past Medical History
• Occupational/Environmental History
Chart Review
• Family History
• Social And Environmental History
• Review of Systems
• Geographic exposure
• Activities of Daily Living
• Advance directives
4
Interviewing
Purposes
• To establish a rapport with patient
• To obtain essential diagnostic information
• To help monitor changes in the patient’s symptoms

over time and response to treatment
13
Interviewing (cont.)
Technique
• Introduce yourself in the social space.(4-12 feet)
• Interview in the personal space.(2-4 feet)
• Use appropriate eye contact.
• Assume a physical position at the same level with the
patient.
• Avoid the use of leading questions; use neutral
questions.
14
Guidelines (Box 15-1)

Undivided interest in the patient
• Provide for privacy
• Review the chart ahead of interview
• Be attentive and respond to the patients concerns, feelings and comforts.
Establish a professional role during introduction

• Dress the part and enter with a smile
• Shake their hand and state your role and purpose for visit
• Address adults as Mr., Mrs., Ms. AND by their LAST name
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Guidelines (Box 15-1)

Show your respect for Belief’s, Attitudes, and Rights
• Ask permission to come in or to move any of their belongings.
• Position yourself so that eye contact is comfortable (eye to eye)
• Avoid standing at the foot of the bed or with your hand on the
door
• Be HONEST, and never guess at an answer. ROLE FIDELITY!
• Listen and then repeat what you heard not only for clarity but to
acknowledge that the patient has been heard.
• Encourage the patient to express his or her concerns and tell
them when you will be back if an answer is expected.
• Never argue
16
Common questions to ask for each symptom

• When did it start?
• How severe is it?
• Where on the body is it?
• What seems to make it better or worse?
• Has it occurred before?
17
Types of Questions:
Open ended questions: encourage patients to describe

events as they see them. “what brought you to the hospital?” or
“what happened next?” This encourages conversational flow
and rapport.
Closed Questions: focus on specific information and provide

clarification. “how long did the pain last?”
18
6
Types of Questions:
Direct questions: cause the patient to minimize their
responses to questions. “Why?” asked too many times can
cause a patient to shy away from the issue.
Indirect Questions: are less threatening than direct questions.

“If I understood you correctly” or “I gather that YOUR doctor has
told you…..”
Neutral Questions: are preferred for all interactions
with the patient. “what happened next?” or “tell me
more…..”
19
Cardiopulmonary Symptoms
Dyspnea
– Sensation of breathing discomfort by patient
(subjective feeling)
• Orthopnea: dyspnea in the reclining position;

associated with CHF and other cardiac issues
• Platypnea: dyspnea when moved to the upright

position
Breathlessness: unpleasant urge to breathe.

• Can be triggered by acute hypercapnia and acidosis
and by hypoxemia
20
(cont.)
Language of Dyspnea
Ask patient about quality and characteristics
of dyspnea (may provide insight into its
causes)
– Patients w/ asthma frequently complain of
chest tightness
– Patients w/ interstitial lung disease may
complain of increased WOB, shallow breathing
and gasping
– Patients w/ CHF may complain of feeling
suffocated
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Assessing Dyspnea During an
Interview (Cont.)
• In patients with chronic cardiopulmonary
disease, a detailed and systematic history
should cover four major areas:
– What ADL tend to trigger episodes of
dyspnea
– How much exertion makes the patient stop
to catch breath
– Whether the quality or sensations of
breathing discomfort varies with different
activities
– Ask the patient to recall when dyspnea first
began and how it has evolved over time
22
(cont.)
Assessing dyspnea during an interview:
– Pay attention to whether patient can speak in

full sentences
– Questions should be brief and limited to quality
and intensity of dyspnea and circumstances of
symptom onset
– Assessment should correspond with gross
examination of patient’s breathing pattern
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,2

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(cont.)
• Panic Disorders and Hyperventilation
– Psychogenic hyperventilation syndrome: when patients
have normal cardiopulmonary function complain of
intense dyspnea and suffocation
– May coincide with symptoms, such as chest pain,
anxiety, palpitation, and paresthesia
– Anxiety often accompanied by breathlessness and
hyperventilation
• RT must always approach any situation involving
hyperventilation or dyspnea as if it had a
pathogenic basis
– Vital signs, ABG, perhaps 12-lead ECG
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,2

1973, 1969 by Mosby, an irint of Elsevier Inc. 4
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Cough
• Most common, nonspecific symptom
observed in patients with pulmonary
disease
• Cough occurs when cough receptors in
airways are stimulated by inflammation,
mucus, foreign material, or noxious gases
• Often impaired in patients with:
– cardiopulmonary, neurologic or neuromuscular
diseases, postoperative period following upper
abdominal surgery or thoracic surgery, after
trauma due to pain
26
Cough (Cont.)
• RT should note characteristics of the
patient’s cough
• Characteristics include:
– Dry or loose, productive or nonproductive,
acute or chronic, and whether it occurs
more frequently at particular times (e.g., day
or night)
– A chronic cough is one lasting 8 weeks or
longer
27
9
Causes of Chronic Cough
• Upper airway cough syndrome (UACS)
– Formerly known as “postnasal drip”
• Asthma
• Gastroesophageal reflux
• Chronic bronchitis associated with
cigarette smoking
• ACE-1 Cough
– Caused by the antihypertensive drug
angiotensin-converting enzyme inhibitor
• Nonasthmatic eosinophilic bronchitis
28
Cardiopulmonary Symptoms (cont.)
Sputum production
• Mucus that comes from the lower airways is “phlegm”
BUT WHEN expectorated through the mouth is called
“sputum.”
• Sputum that has pus cells in it is said to be “purulent.”
• Sputum that is foul smelling is “fetid.”

• Sputum that is clear and thick is “mucoid” (asthma)
• Recent changes in the color, viscosity, or quantity of

sputum may indicate infection.
29
Cardiopulmonary Symptoms (cont.)

• Coughing up blood or blood-streaked sputum from the
lungs
• Massive
– More than 300 ml of blood expectorated over 24 hours
– Common causes: bronchiectasis, lung abscess, and acute or
chronic tuberculosis
– Distinguished from hematemesis (vomiting blood from
gastrointestinal tract)
• Nonmassive
– Common causes include: infection of airway, tuberculosis,
trauma, and pulmonary embolism
10
Hemoptysis
Chest pain
• Pleuritic chest pain—located laterally or
posteriorly
– Sharp, and increases with deep breathing
(pneumonia and pulmonary embolism)
• Nonpleuritic chest pain—located in center
of chest and may radiate to shoulder or
arm; it is not affected by breathing
– Often caused by angina, gastroesophageal
reflux, esophageal spasm, chest wall pain, and
gall bladder disease
32
Fever
• Elevation of body temperature due to disease
(>38.3° C; 101° F)
• May occur with simple viral infection of upper
airway or with serious bacterial pneumonia,
tuberculosis, and some cancers
• Causes increased metabolic rate, oxygen
consumption, and carbon dioxide production
• Particularly dangerous in patients with severe
chronic cardiopulmonary disease because it may
cause acute respiratory failure
33
11
Pedal Edema
• Swelling of lower extremities—most often
due to heart failure
• Two subtypes:
1. Pitting edema—indentation mark left on
skin after applied pressure
2. Weeping edema—small fluid leak occurs
at point where pressure applied
• Patients with chronic hypoxemic lung
disease usually develop right heart failure
(cor pulmonale) due to pulmonary
hypertension
34
Pedal edema
Medical History
• The first priority of the RT reviewing the
medical record is to ensure that all
respiratory care procedures are supported
by a physician order that is current, clearly
written, and complete
• Then review the patient’s medical record
by reading about current medical
problems.
36
12
Format for the Medical History
• Familiarizes clinician with patient’s condition
• Reviewing patient’s chart:
– Chief complaint (CC)/ history of present illness (HPI)
• Explains current medical problems
– Past medical history (PMI)
• Smoking history is often recorded in pack-years
• Packs smoked per day × number of years smoked
– Family/Social/Environmental history
• Potential genetic or occupational links to disease and the
patient’s current life situation
– Review of systems (ROS)
– Advance directive
37
Medical History
Pack years (cont.)

If patients state that they have smoked more or
less than a whole pack:
30 cigarettes / 20 cigarettes per pack = 1.5 packs

1.5 packs X 20 years = 30 pack years smoking history
15 cigarettes / 20 cigarettes per pack = 0.75 packs

0.75 packs X 20 years = 15 pack years smoking history
38
65 year-old female states that she has been smoking for

40 years and approximately 1/2 pack of cigarette per
day. How would you document this patient’s smoking
history for the record?
A.10 pack-year
B.20 pack-year
C.30 pack-year
D.40 pack-year
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,3

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Physical Examination
Essential for evaluating patient’s problem

and determining ongoing effects of therapy
Consists of 4 steps:
1. Inspection (visually examining)
2. Palpation (touching)
3. Percussion (tapping)
4. Auscultation (listening with stethoscope)
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General Appearance
Done during first few seconds of patient encounter,

how does your patient look?
Indicators to assess:
– Level of consciousness
– Facial expression
– Level of anxiety or distress
– Body positioning
– Personal hygiene
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,4

1
Level of Consciousness
• Sensorium: Level of consciousness and

orientation to time, place, person and
situation (oriented x 4)
• Reflects oxygenation status of brain
• Affected by poor cerebral blood flow
(hypotension)
• If patient is not alert—standard rating scale is
used to objectively describe patient’s level of
consciousness (Box 16-6, p. 329)
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Physical Examination
• Easy to obtain and provide useful information

about current health status
• The vital signs (VS) are easy to obtain and

provide useful information about the current
health status of the patient.
• Vital Signs = RR, HR, BT, BP
43
Body Temperature
• Normal: 98.6 oF or 37.0 oC

• Increased temperature: Hyperthermia or
hyperpyrexia (fever) aka“febrile”
• Hypothalamus plays major role in heat regulation
(vasodilation and diaphoresis. Respiratory system also removes excess heat
through ventilation)
• Decreased temperature: Hypothermia (cold exposure)
• Can be measured at: mouth, axilla, ear or rectum

• Rectal temp: closest to core body temperature
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,4
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Heart Rate (HR)
• Evaluate rate, rhythm and strength
• Tachycardia: HR>100 beats/min.

– Causes: fear, anxiety, low B/P, anemia, low PaO2
• Bradycardia: HR<60 beats/min

– Causes: hypothermia, medications, TBI
• Measure for full minute if pulse is irregular
• Pulsus paradoxus vs. pulsus alternans

Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,4
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Respiratory Rate (RR)
• Resting adult RR is 12 to 18 breaths per minute

(bpm)
• Tachypnea >20 bpm
• Bradypnea <10 bpm
• Do not reveal assessment of RR to patient
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,4

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Blood Pressure (BP)
• Systolic: 90 to 140 mmHg

• Diastolic: 60 to 90 mmHg
• Pulse pressure: difference between systolic and
diastolic. Usually 30 to 40 mmHg
• Hypertension: BP persistently >140/90 (90% cases
cause is unknown e.g. IPAH)
• Hypotension: Systolic BP <90 mmHg or mean art.
pressure <65 mmHg (shock, hypovolemia)
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,4
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Vital Signs (VS)
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,4

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Head and Neck Exam
• Nasal flaring is often seen in infants with respiratory

distress and an increase in the WOB.
• Cyanosis of the oral mucosa indicates respiratory

failure due to low oxygen levels.
• Pursed-lip breathing is seen in patients with COPD

who have obstruction of the small airways. Promotes
emptying of the lungs
49
Head and Neck Exam (cont.)
• The trachea should be midline; it may shift left or right

with upper lobe abnormalities or mediastinal tumors.
• A 3- 4 cm enlargement of Jugular venous distention

(JVD) is seen in patients with left heart failure (CHF) but
most commonly right heart failure (cor pulmonale).
• Enlarged lymph nodes in the neck may occur with

infection or malignancy.
JVD
17
Examination of the Thorax and
Lungs
• Inspection
• Chest should be inspected visually to
assess:
– The thoracic configuration
– Expansion
– The pattern and effort of breathing
– Make every effort to respect the patient’s
modesty
52

Lungs (Cont.)
• Thoracic configuration
– The anteroposterior (AP) diameter of the
average adult thorax is less than the
transverse diameter
– The abnormal increase in AP diameter is
called barrel chest
• Associated with emphysema
53

Lungs (Cont.)
• Thoracic configuration (Cont.)
– Pectus carinatum
• Abnormal protrusion of sternum
– Pectus excavatum
• Depression of part or entire sternum, which
can produce a restrictive lung defect
54
18
Lungs (Cont.)
• Thoracic configuration (Cont.)
– Kyphosis
• Spinal deformity in which the spine has an
abnormal AP curvature
– Scoliosis
• Spinal deformity in which the spine has a
lateral curvature
– Kyphoscoliosis
• Combination of kyphosis and scoliosis,
which may produce a severe restrictive lung
defect as a result of poor lung expansion
55

Lungs (Cont.)
• Thoracic expansion
– Diaphragm is the primary muscle of breathing
– Normal chest wall expands symmetrically and
can be evaluated on the anterior and posterior
chest
– Diseases that affect the expansion of both
lungs cause a bilateral reduction in chest
expansion
• Reduced expansion commonly is seen in
neuromuscular disorders and COPD
• Unilateral reduction in chest expansion
occurs with respiratory diseases that reduce
the expansion of one lung or a major part of
one lung
56
Breathing Pattern and Effort

• Abnormal breathing pattern—broken into
two broad categories:
1. Those directly associated with
cardiopulmonary or chest wall diseases
that increase work of breathing
2. Those associated with neurologic disease
57
19
(Cont.)
• Common causes of an increase in WOB
include:
– Narrowed airways (e.g., COPD, asthma)
– “Stiff lungs” (e.g., acute respiratory distress
syndrome, cardiogenic pulmonary edema)
– A stiff chest wall (e.g., ascites, anasarca,
pleural effusions)
• One sign of severely increased work of
breathing is visable distortions in chest
wall, called retractions
58

(Cont.)
• Retractions are an inward sinking of the
chest wall during inspiration
– Intercostal, supraclavicular, or subcostal
retractions
• Occurs when inspiratory muscle
contractions generate very large negative
intrathoracic pressures
• Tracheal tugging
– The downward movement of the thyroid
cartilage toward the chest during inspiration
59

(Cont.)
• Two typical abnormal breathing patterns
exist
(1) A rapid, shallow breathing pattern
(2) A relatively brief inspiratory phase with an
abnormally prolonged exhalation
characterized by pronounced, sustained
abdominal muscular contraction
• Can provide clues about the underlying
pulmonary problem
60
20
(Cont.)
• Apnea
– Characteristic: No breathing
– Causes: Cardiac arrest, narcotic overdose,
severe brain trauma
• Apneustic breathing
– Characteristic: Deep, gasping inspiration
with brief, partial expiration
– Causes: Damage to upper medulla or pons
caused by stroke or trauma; sometimes
observed with hypoglycemic coma or
profound hypoxemia
61

(Cont.)
• Ataxic breathing
– Characteristic: Completely irregular breathing
pattern with variable periods of apnea
– Causes: Damage to medulla
• Asthmatic breathing
– Characteristic: Prolonged exhalation with
recruitment of abdominal muscles
– Causes: Obstruction to airflow out of the lungs
• Biot respiration
– Characteristic: Clustering of rapid, shallow breaths
coupled with regular or irregular periods of apnea
– Causes: Damage to medulla or pons caused by
stroke or trauma; severe intracranial hypertension
62

(Cont.)
• Cheyne-Stokes respiration
– Characteristic: Irregular type of breathing;
breaths increase and decrease in depth and
rate with periods of apnea; variant of
“periodic breathing”
– Causes: Most often caused by severe
damage to bilateral cerebral hemispheres
and basal ganglia (usually infarction); also
seen in patients with CHF owing to
increased circulation time and in various
forms of encephalopathy
• Kussmaul breathing
– Characteristic: Deep and fast respirations
– Causes: Metabolic acidosis
63
21
(Cont.)
• Paradoxical breathing
– Characteristic: Abdominal paradox—
Abdominal wall moves inward on
inspiration and outward on expiration
– Causes: Abdominal paradox—
Diaphragmatic fatigue or paralysis
– Characteristic: Chest paradox—Part or all
of the chest wall moves in with inhalation
and out with exhalation
– Causes: Chest paradox—Typically
observed in chest trauma with multiple rib
or sternal fractures; also found in patients
with high spinal cord injury with paralysis
of intercostal muscles
64

(Cont.)
• Periodic breathing
– Characteristic: Breathing oscillates
between periods of rapid, deep breathing
and slow, shallow breathing without periods
of apnea
– Causes: Most often caused by severe
damage to bilateral cerebral hemispheres
and basal ganglia (usually infarction); also
seen in patients with CHF owing to
increased circulation time and in various
forms of encephalopathy
65
Chest Palpation
• Palpation is the art of touching the chest
wall to evaluate underlying structure and
function
• Vocal and tactile fremitus is increased with
pneumonia and atelectasis (consolidation)
• Vocal and tactile fremitus is reduced with
emphysema, pneumothorax, and pleural
effusion
66
22
Chest Palpation (Cont.)
• Bilateral reduction in chest expansion—
seen in neuromuscular disorders and
COPD
• Unilateral reduction in chest expansion:
consistent with pneumonia or
pneumothorax
• Air leaks into subcutaneous tissues causes
“crepitus”—sign of subcutaneous
emphysema
67
Chest Percussion
• Performed systematically by consecutively
testing comparable areas on both sides of
the chest
• Resonance of chest evaluated with
percussion
• Findings should be labeled as “normal,”
“increased,” or “decreased” resonance
– Decreased resonance—pneumonia or
pleural effusion (consolidation)
– Increased resonance—emphysema or
pneumothorax (air)
68
Chest Auscultation
Technique of Auscultation
• Patient should be sitting upright in relaxed position
• Patient should breathe a little more deeply than normal
through an open mouth
• Exhalation should be passive
(the stethoscope should be against the chest wall itself and
avoid listening over clothing)
• Auscultation should include ALL lobes (anterior, lateral,
posterior)
• Should begin at the bases up to the apexes
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Auscultation of the Lungs
• Tracheal breath sounds
– Heard directly over trachea; created by
turbulent flow; loud with expiratory
component equal to or slightly longer than
inspiratory component
• Bronchovesicular breath sounds
– Heard around sternum; softer and slightly
lower in pitch
• Vesicular breath sounds
– Heard over lung parenchyma; very soft and
low pitched
71
Chest Auscultation
• Lung sounds come in two varieties: breath sounds and

adventitious lung sounds.
• Breath sounds = the normal sounds of breathing
• Adventitious Lung Sounds = the abnormal sounds

superimposed on the breath sounds (crackles and
wheezes)
72
24
Chest Auscultation (cont.)
Breath sounds
• Tracheal breath sounds: heard directly over the trachea
and created by turbulent flow; loud and high-pitched
• Bronchovesicular breath sounds: heard around
sternum; softer and slightly lower in pitch
• Vesicular breath sounds
– Muffled, low-pitched sound heard over lung parenchyma;
– represent attenuated (filtered) turbulent flow sounds from the
larger airways
– Heard primarily during inhalation, which is one-third longer
than expiration
– Normal vesicular lung sounds essentially are attenuated
tracheal breath sounds
73
Mechanism and Significance of

Lung Sounds (Cont.)
• Bronchial breath sounds
– Abnormal if heard over peripheral lung
regions
– Replacing normal vesicular sounds when
lung tissue density increases
– Sign of consolidation
• Diminished breath sounds
– Occur when sound intensity at site of
generation (larger airways) is reduced due
to shallow or slow breathing, or
– When sound transmission through lung or
chest wall is decreased (COPD or asthma)
74
Adventitious lung sounds

2 varieties:
1. Discontinuous
• Intermittent crackling
• Bubbling sounds of short duration
• Referred to as “crackles”
2. Continuous
• Referred to as “wheezes”
• Called “stridor”if heard over the upper airway
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25
Wheezes
– Airway walls that are narrowed
– consistent with airway obstruction
– After bronchodilation expiratory wheezes will decrease in
pitch and length
– monophonic wheezing indicates one airway is affected
– polyphonic wheezing indicates many airways are
involved.
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Stridor
– Loud, high pitched sound
– Upper airway compromised
– Indicates obstruction in the trachea or larynx
– Acute stridor—croup
– Inspiratory stridor—narrowing above glottis
– Expiratory stridor—narrowing of lower trachea
77
Coarse crackles
– Airflow moves secretions or fluid in airways
– Usually clears when patient coughs or upper
airway is suctioned
– Crackles are heard when airways pop open
Early inspiratory crackles

– Usually scant but may be loud
– Not silenced by cough or change of position
– Indicates severe airway obstruction (COPD)
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26
Fine LATE inspiratory crackles

– Sudden opening of small airways late in the
inspiratory phase
– Due to the peripheral airways collapse during
exhalation
– Most common in Respiratory Disorders
– Heard w/ pulmonary fibrosis, atelectasis,
pneumonia, and pulmonary edema
79
Pleural Friction Rub

– Creaking or grating sound with pleural
inflammation
– Sounds similar to coarse crackles not affected
by coughing
– Intensity increases with deep breathing
Bronchophony
– Increased intensity of vocal resonance
– Indicates lung tissue density
– Occurs in consolidation phase of Pneumonia
80
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Cardiac Examination
• The chest wall overlying the heart is known as the

precordium.
• It is inspected, palpated, and auscultated for

abnormalities.
• Point of maximal impulse (PMI)

• In patients with pulmonary hyperinflation (COPD). PMI
may be difficult to palpate due to the increased AP
diameter AND changes in lung tissue
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Cardiac Examination (cont.)
Auscultation of the heart

•Normal heart sounds are created by closure of the heart
valves:
– S1 is created by closure of the AV valves.
– S2 is created by closure of the semilunar valves.
– An S3 is abnormal in adults and caused by rapid filling of a

stiff left ventricle.
– An S4 is caused by an atrial “kick”

” of blood into a
noncompliant left ventricle.
•When a patient has both an S3 and an S4, a gallop rhythm is present.
83
A murmur is an abnormal heart sound most often

heard over the precordium.
– Murmurs are produced by blood flowing through a narrowed
opening.
Systolic murmurs are caused by stenotic semilunar valves

and incompetent AV valves.
– Produce a high pitched “whooshing” sound with S1
Diastolic murmurs caused by stenotic AV valves or

incompetent semilunar valves
84
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Abnormal Heart Sounds

Diminished heart sounds S1 and S2 can be caused due to:
• Pulmonary hyperinflation, pleural effusion,
pneumonthorax and obesity
• Force of ventricular concentration is poor (heart failure)
Murmurs are created by

– Backflow of blood through an incompetent valve
– Forward flow of blood through a stenotic valve
– A rapid flow of blood through a normal valve
85
Abdominal Exam
• The abdomen is inspected and palpated for distention

and tenderness.
• An enlarged liver (hepatomegaly) is consistent with cor

pulmonale.
• Abdominal paradox is present when the abdomen sinks

inward during inspiration; this is a sign of diaphragm
fatigue.
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Examination of the Extremities
Respiratory disease may cause

several abnormalities of the
extremities:
• Digital clubbing
• Cyanosis
• Pedal edema
• Capillary refill
• Peripheral skin temperature
87
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• Digital clubbing is not common but is seen in a large variety of
chronic conditions: congenital heart disease, bronchiectasis,
various cancers, and interstitial lung diseases.
88
Clubbing

(cont.)
Digital cyanosis is often a sign of poor perfusion;
the hands and feet are typically cool to the touch in such
cases.
Peripheral cyanosis
• Cyanosis of the digits
• Due to poor perfusion, especially in the extremities
• When flow is poor, tissues extract more O2 thus a
decrease venous O2 content
Cool extremities is an indicator of poor perfusion and
peripheral cyanosis
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(cont.)
Pedal Edema
•Usually is a result from heart failure
•Increase in hydrostatic pressure of the venous system
•Leaking fluid into surrounding tissue
•Edematous tissues “pit” or indent when pressed firmly with a finger, referred
to as pitting edema
Capillary Refill
•Assessed by pressing briefly and firmly on patient fingernail until blanched
•When pressure is released, color returns (normally within 2 sec or less)
A decreased cardiac output and poor digital perfusion

could cause several seconds to return
91

(cont.)
Peripheral Skin Temperature
• Extremities cool to the touch
• As it cools back to the torso it indicates heart
failure
• systemic perfusion is poor (heart failure)
• Compensatory vasoconstriction to shunt blood
to vital organs
92
Clinical Laboratory Studies

• Complete Blood Count (CBC)
– Red Blood Cell (RBC) Count
– Hemoglobin
– Hematocrit
– White Blood Cell (WBC) Count
– Platelet Count
31
Coagulation Studies
Ptt= Partial Thromboplastin Time

– Assesses intrinsic pathways for plasma to
form a fibrin clot
– Norm approximately 25-35 seconds
PT= Prothrombin Time

– Assesses extrinsic pathways for plasma to
form a fibrin clot
– Norm 12-15 seconds
Chemistry Results
• Sodium (Na+)
• Mainly Responsible For Osmotic Pressure of

Extracellular Fluid
• Considered the major cation of the

extracellular fluid
• Normal Value: 136 – 145 mEq/L
Sodium (Na+)
• Causes of Hypernatremia (High Na+)
– Profuse Sweating
– Diarrhea
– Renal Disease
– Prolonged Hyperpnea
32
Potassium (K+)
• Major Cation Occurring Within Cells
• Normal Value: 3.5 – 5 mEq/L
Potassium (K+)
• Causes of Hypokalemia (Low K+)
– Side effect of Albuterol
– Decreased K+ Intake
• Low Potassium Diet
• Alcoholism
Causes of Hypokalemia (Low K+)
• Increased Loss of Potassium
– Gastrointestinal Loss
– Renal Disease
– Diuretics
33
Causes of Hypokalemia (Low K+)
• Extracellular to Intracellular Shift of

Potassium
– Alkalosis
– Increased Plasma Insulin
– Diuretic Use
Chloride (Cl-)
• Chief Anion in Extracellular Fluid
• Normal Value: 98 – 106 mEq/L
Chloride (Cl-)
• Causes of Hyperchloremia
– Prolonged Diarrhea
– Certain Kidney Diseases
– Hyperparathyroidism
34
Blood Urea Nitrogen (BUN)
• Used in Assessing Renal Function
• Normal Value: 7 – 20 mg/dl
Creatinine (Cr)
• Waste Product Formed Within Muscle Tissue
And Filtered Out by The Kidneys
• Normal Value: 0.7 – 1.3 mg/dl
• Increased in Kidney Disease in Which >50%

of Renal Nephrons Destroyed
• Increased in Certain Muscle Disease
Albumin
• Protein That Functions as a Transport And
Storage Substance For Hormones, Drugs,
And Electrolytes
• Secreted by Liver Cells
• Normal Value: 3.5 – 5.0 g/dl
35
Cholesterol
• Lipid used as Fuel Storage And Building
Blocks For Hormones, Cell Walls, Etc
• Normal Value: 150 – 220 mg/dl; less than

200 desirable
• Separated by Centrifuge Into High Density

Lipids (HDL) And Low Density Lipids (LDL);
HDL Has Decreased Cardiac Risk
Glucose
• Normal fasting blood sugar levels range

from 70 to 99 mg/dl
• Blood glucose is needed to create energy
• An elevated blood glucose is known as

hyperglycemia and most often occurs from
type II diabetes
• A reduced blood glucose is known as

hypoglycemia
Mixed Venous Partial Pressure

of Oxygen (PvO2)
• Indicative of Tissue Oxygenation(true mixed venous
can only be obtained by a pulmonary artery blood sample from PAC)
• Normal Value: 38 – 42 mmHg
• Decrease Indicates Tissue Oxygenation

Less Than Optimal
• May Indicate Impairment of Circulation
36
Arteriovenous Oxygen Content
Difference C(a-v)O2
• Arterial and Mixed Venous Blood Sampled
Simultaneously
• Approximate Normal Value: 5.0 ml/dl / vol%
Carboxyhemoglobin (HbCO)
• Indicates Quantity of Carbon Monoxide

Bound to Hemoglobin
• Normal Value: 0.5%
• Mildly Elevated (5% - 10%) With Cigarette

Smoking
• Elevation of > 10% With Inhalation of Large

Quantities of Smoke, Exhaust, Etc
Chest Radiograph Introduction

• Chest imaging is crucial in the practice of
pulmonary and critical care medicine
• RT needs to be able to recognize
significant radiographic abnormalities in
certain situations
• Various chest imaging techniques exist
– Chest film (more accurately called a
radiograph)
– Computed tomography (CT) scanning
– Ultrasound
– Magnetic resonance imaging (MRI).
111
37
• Nuclear medicine
– A separate branch of medicine that uses radioactive
material to produce images
• Radioactive material is administered to patients by
intravenous (IV) injection, inhalation, or oral
ingestion
• In the chest, commonly performed nuclear
medicine studies are:
– Vሶ /Qሶ (for ventilation-perfusion) scans
• Pulmonary embolism
– PET-CT (for positron emission tomography-CT)
• Stage cancer patients
112
Overview of the Chest Radiograph

• Chest radiograph is created by passing x-
ray beam through chest
• X-ray beam strikes film after passing
through chest
– X-rays passing through lung turn film black
– X-rays absorbed by more dense tissue (e.g.,
bone) leave film white
• Resulting chest radiograph represent
various shades of gray shadows
113

(Cont.)
• Four different tissue densities are visible on
normal chest radiograph
– Air, fat, water, and bone
• Each tissue type absorbs different proportions of
the x-ray beam
– Air in the lung, stomach, or intestines absorbs very
few x-rays and appears virtually black (radiolucent)
– Fat absorbs a small amount of the x-ray beam and is
usually seen as a light-gray shadow
– Soft tissue absorbs a slightly greater amount of the
x-ray beam and is usually seen as a medium-gray
shadow
– Bone absorbs a large fraction of the x-ray beam and
is seen as a nearly white (radiopaque) shadow
114
38
(Cont.)
• Digital technology has replaced traditional
photographic film
• Currently, most x-rays are recorded and
displayed in digital format on a picture
archiving and communication system
(PACS)
• Digital films have advantages:
– Can be manipulated to enhance interpretation
– Can be stored and retrieved quickly from any
location/time
– Can be copied, shared, and transported quickly
– Image quality does not deteriorate over time
115
Indications for Obtaining a Chest

Radiograph
• Outpatient
– Unexplained dyspnea, severe persistent
cough, hemoptysis, fever and sputum
production, acute sever chest pain, positive
TB skin test
• Inpatient
– Placement of tubes and catheters, sudden
onset of dyspnea or chest pain, elevated or
changing plateau pressure during
mechanical ventilation, sudden decline in
oxygenation
116
Approach to Reading a Plain Chest

Film
• Disciplined approach is needed
• Steps in reviewing a chest film are as
follows:
– Identify the name on the radiograph
– Review the technique and quality of the
exam
– Systematically review the anatomic
structures on the chest film to assess their
normality or abnormality
117
39
Chest Radiograph
X- ray
• Reflected light but penetrates most matter
Chest radiograph
Placing a sheet of film next to the patients

thorax opposite the x-ray tube.
Radiolucent
X-ray that pass through low density tissue
Chest Radiograph
– Radiopaque
• X-ray that is partially absorbed by dense

tissue (bone)
• Seen as white shadows on the film
Chest Radiograph Technique and

Quality
• Is the radiograph appropriately labeled?
• Is the study performed with PA and lateral
views, or is it an anteroposterior (AP)
portable exam?
• Is the entire chest imaged (i.e., are any
structures not included)?
• Was the patient properly positioned?
• Were the optimal settings for the x-ray
beam selected when the film was taken?
Copyright © 2017 Elsevier Inc. All Rights Reserved. 120
40
PA Chest Film
• PA chest film is created in radiology
department, usually with patient standing
• X-ray beam passes from posterior to
anterior (PA), with film placed against
patient’s chest
• Usually results in high-quality film with
minimal magnification of heart shadow
AP Chest Film
• Taken with portable x-ray machine in ICU
• X-ray source is in front of patient and film
is behind patient
• AP films are often more difficult to read
because quality is not as good as PA film
• Heart shadow is more magnified with AP
film because heart is closer to x-ray source
and farther from film
• Rotation of patient is more likely
Film Penetration
• Improper penetration may conceal
structures and important details
• Proper penetration shows intervertebral
disc spaces through shadow of heart
• Underexposed or underpenetrated films
show an increase in chest whiteness
(white-out x-ray)
• Overexposed or overpenetrated films leave
lung parenchyma black without vascular
markings
41
Anatomic Structures Seen on a
Chest Radiograph
• Bones (e.g., ribs, clavicles, scapulae,
vertebrae)
• Soft tissues (e.g., tissues of the chest wall,
upper abdomen, lymph nodes)
• Lungs
• Pleura
• Heart, great vessels, and mediastinum
• Upper abdomen
• Lower neck
Chest Anatomy on The Film
Normal Chest Films
42
Views
• Lateral View
– Commonly Left Side Placed Against X-Ray

Plate
– Minimizes Cardiac Magnification
Views
• Lateral Decubitus View
– Patient Lying on Right or Left Side
– Able to Detect Presence of Fluid in The Chest

(as little as 50-100 ml of pleural fluid)
– May be Helpful in Detection of Pneumothorax
Views
Oblique Views
° to Right or Left With

– Patient Turned 45°
Anterolateral Chest Against Film
– Helps to Delineate a Pulmonary or

Mediastinal Lesion
Expiratory Views
– Helpful in identifying small pneumothorax
43
Interpretation
• X-ray penetration inversely proportional
to density of structure
• Normal lung tissue has low density

Cavities, blebs (darker)
• Consolidation increases density

Pneumonia, tumor, collapse (white patch)
• Greatest density in the chest: bones
• Systematic review of all structures
Silhouette Sign and Air

Bronchogram
Silhouette sign
Infiltrate that obliterates heart border or
diaphragm must be located in anterior
segments of the lung
Air bronchogram
Visible bronchi when surrounded by
consolidated alveoli
Confirms intrapulmonary disease, though
absence does not rule it out
Air Bronchograms
44
Right Middle Lobe Pneumonia
Clinical and Radiographic Findings

in Lung Diseases
• Atelectasis
• Hyperinflation
• Congestive heart failure (CHF)
• Pleural effusion
• Consolidation
Atelectasis
• Compressive atelectasis seen in patients with:

– Pleural effusion, pneumothorax, hemothorax
– If severe: mediastinal shift
• Obstructive atelectasis
– Tumor, aspirated foreign body, mucus plugging
• Postoperative atelectasis
– Microatelectasis
• CXR: lung volume loss, mediastinal shift
45
Assessing Lung Volume (Cont.)
136
Pneumothorax
• Often causes atelectasis
• Tension pneumothorax
– Mediastinal shift
– Tracheal deviation away from affected side
– Pleural line
Pneumothorax
46
Tension Pneumothorax

• Hyperinflation
• Commonly seen with emphysema
• If more than seven anterior ribs above
diaphragm, hyperinflation is present
• Other signs of hyperinflation include:
– Flattening of hemidiaphragms
– Large retrosternal airspace
– Narrowed mediastinum
– Increased AP diameter
140
47
Pulmonary Edema
• Pulmonary edema due to left heart failure is
common finding on chest radiograph
• Left heart failure causes enlargement of
pulmonary blood vessels in apex of lung
(cephalization)
• Kerley B lines
– Thin lines seen near the pleural edge on a chest
film as a result of increased pulmonary capillary
pressures
• Bat wing appearance
– applied to the predominance of edema in the
hilar regions of both lungs with progressively
less edema in the more peripheral areas of the
lungs
Pulmonary Edema (Cont.)

• Radiographic signs of cardiac
decompensation include the following:
– Cardiac enlargement
– Pleural effusions, usually bilateral
– Redistribution of blood flow to the upper
lobes (cephalization of blood flow)
– Poor definition of the central blood vessels
(perihilar haze)
– Kerley B lines
– Alveolar filling
143
Pulmonary Edema (Cont.)
144
48
Interstitial Lung Disease
• Chest radiograph usually shows diffuse, bilateral
infiltrates
• Opacities may resemble scattered, poorly defined
nodules
• Many different types—two most common:
– Idiopathic pulmonary fibrosis
– Sarcoidosis
• Because most patients have similar findings, it
does not usually establish specific diagnosis
• HRCT has become an important tool in
establishing the specific form of interstitial lung
disease that a patient may have
145
Interstitial Lung Disease (Cont.)
Pleural Effusion
• Small volume effusion:

– Blunting of the costophrenic (CP) angle
– Small meniscus sign as fluid fills the space
between the lung and wall then we see a partially
obscured and elevated diaphragm
• Large volume effusion

– Complete or nearly complete whiteout
– Complete obscuring of the hemidiaphragm
• Confirm with lateral decubitus
49
Pleural Effusion
• Also called a hydrothorax
• Is the accumulation of excess fluid within
the pleural space
• Blunted costophrenic angle on chest x-ray
indicates pleural effusion is present
– About 200 ml of pleural fluid will blunt
costophrenic angle
• Best chest x-ray view for detecting small
pleural effusion is lateral decubitus
Pleural Effusion (Cont.)

• Pleural fluid generally is categorized as
either a transudate or an exudate
• Loculation of pleural fluid
– The trapping so that the fluid does not
move freely with changing positions
• Hemothorax
– Blood in the pleural space
• Empyema
– Infection of the pleural fluid
• Ultrasound and CT can detect fluid
149
Pleural Effusion (Cont.)
50
Consolidation
• Minimal volume loss

• Bacterial pneumonia is the most common cause
• Homogeneous density
Physical findings would be:

• Reduced resonance to percussion
• Fine crackles
• Tachypnea and fever
51
Post Procedural X-Rays
• Tracheal Intubation
– Evaluate Position of Endotracheal Tube
– Inferior Tip Approximately 3 to 5 cm Above

The Carina
– If Tube is Repositioned, Repeat X-Ray May be

Done
Advanced Chest Imaging

• Computed tomography (CT) is very helpful
in certain situations
• CT visualizes structures cross-sectionally
with great detail—up to ~2 mm structures
inside lung
• CT scanning creates images looking like
“slices” of patient’s chest (5 to 7 mm
thick)
• Conventional CT scanning is used to
evaluate lung nodules and masses, great
vessels, mediastinum, and pleural disease
Advanced Chest Imaging (Cont.)

• High-resolution CT (HRCT) scanning
examines 1-mm slices of lung, producing
greater lung detail
• High-resolution CT scanning is ideal for
evaluating diffuse parenchymal lung
diseases:
– Interstitial lung disease
– Emphysema
– Bronchiectasis
52
• Computed tomography angiography
– Rapid scanning that can be performed on
helical CT scanners has made CT
angiography possible
• CT angiography of the chest used to
identify pulmonary embolism
• Capabilities of modern CT scanners allow
for reconstruction of the chest in any
direction and production of three-
dimensional representations
– Virtual bronchoscopy
CT Angiograms
Magnetic Resonance Imaging

• Uses radio waves from realigning
hydrogen nuclei to generate MRI image
(no x-rays are used)
• Most often used to image mediastinum,
hilar regions, and large vessels in lung
• MRI has limitations in chest medicine
– Cannot be used in patients with pacemaker
– Metal objects (e.g., gas cylinders or regular
ICU ventilators) cannot be used near MRI
machine
53
Ultrasound
• Images created by passing high-frequency
sound waves into body and detecting
sound waves that bounce back (echo) from
tissues of body
• Ultrasonic evaluation of lung itself is rare
• Uses very portable equipment
• Commonly used to guide placement of
central and arterial catheters and to detect
and quantify pleural effusions
• Very common in ICU
Ultrasound (Cont.)
Endotracheal Tube Placement
54
Endotracheal Tube Placement

• Central Venous Line
– Catheter is Placed Into Right or Left Subclavian

or Jugular Vein
– Placed Just Above Juncture of Right Atrium And

Superior Vena Cava
CVP line placement
55
• Pulmonary Artery Catheter
– Also Known as Swan-Ganz Catheter
– Checked Daily to Monitor Correct Position
– Placed in Pulmonary Artery And Sutured in

Place

• Chest Tube
– Placed to Provide Drainage of Fluid or

Removal of Free Air
– Checked to Ensure That Drainage is Being

Accomplished
Advanced Chest Imaging

• Computed tomography (CT) is very helpful
in certain situations
• CT visualizes structures cross-sectionally
with great detail—up to ~2 mm structures
inside lung
• CT scanning creates images looking like
“slices” of patient’s chest (5 to 7 mm
thick)
• Conventional CT scanning is used to
evaluate lung nodules and masses, great
vessels, mediastinum, and pleural disease
56
• High-resolution CT (HRCT) scanning
examines 1-mm slices of lung, producing
greater lung detail
• High-resolution CT scanning is ideal for
evaluating diffuse parenchymal lung
diseases:
– Interstitial lung disease
– Emphysema
– Bronchiectasis

• Computed tomography angiography
– Rapid scanning that can be performed on
helical CT scanners has made CT
angiography possible
• CT angiography of the chest used to
identify pulmonary embolism
• Capabilities of modern CT scanners allow
for reconstruction of the chest in any
direction and production of three-
dimensional representations
– Virtual bronchoscopy
CT Angiograms
57
Magnetic Resonance Imaging
• Uses radio waves from realigning
hydrogen nuclei to generate MRI image
(no x-rays are used)
• Most often used to image mediastinum,
hilar regions, and large vessels in lung
• MRI has limitations in chest medicine
– Cannot be used in patients with pacemaker
– Metal objects (e.g., gas cylinders or regular
ICU ventilators) cannot be used near MRI
machine
Ultrasound
• Images created by passing high-frequency
sound waves into body and detecting
sound waves that bounce back (echo) from
tissues of body
• Ultrasonic evaluation of lung itself is rare
• Uses very portable equipment
• Commonly used to guide placement of
central and arterial catheters and to detect
and quantify pleural effusions
• Very common in ICU
Ultrasound (Cont.)
58
Radionuclide Lung Scanning
• Obtained by Measuring Gamma Radiation

Emitted From The Chest After Radio-
pharmaceuticals Are Injected Into The Blood
And Inhaled Into The Lungs
• Used to Evaluate Ventilation/Perfusion

States
Radionuclide Lung Scanning

• Separate Perfusion Scan is Compared to
Ventilation Scan
• Most Often Used in Diagnosis of Pulmonary

Embolism
Positron Emission Tomography

(PET)
• Radiopharmaceutical Sugar Water is
Injected; Patient Remains Still for One Hour;
Uptake is Evaluated
• Useful in Diagnosis of Tumors And Areas of

Infection (Increased Metabolic Activity
Results in Greater Uptake)
59
Nutritional Support
• The primary goal of nutrition support is the
maintenance or restoration of lean body
(skeletal muscle) mass
• Accomplished by
– Meeting the patient’s overall energy needs
– Providing the appropriate combination of
substrates to do so
178
Respiratory Impairment and

Malnutrition
179
Respiratory Consequences of
Malnutrition
• Respiratory muscle dysfunction
– Loss of diaphragmatic mass and contractility
– Loss of accessory muscle mass and contractility
• Effect on control of ventilation
– Decreased hypoxic and hypercapnic response
• Increased incidence of respiratory infections
– Decreased lung clearance mechanisms
– Decreased secretory IgA
– Increased bacterial colonization
• Changes in lung parenchymal structure
– Unopposed enzymatic digestion
– Reduced production of surfactant
180
60
Anthropometrics (cont.)
Ideal Body Weight:

– Ideal body weight may also be determined using
formulas:
• Men: 106 pounds for first 5 feet, plus 6 pounds for
each inch over 5 feet
• Women: 100 pounds for first 5 feet, plus 5 pounds for
each inch over 5 feet
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 181
The IBW for a 25 year-old female patient whose

height is measured at 5'5" would be:
155 lb.
. 125 lb.
. 100 lb.
. 130 lb.
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 182
Malnutrition
• Respiratory muscle dysfunction
– Loss of diaphragmatic mass and contractility
– Loss of accessory muscle mass and contractility
• Effect on control of ventilation
– Decreased hypoxic and hypercapnic response
• Increased incidence of respiratory infections
– Decreased lung clearance mechanisms
– Decreased secretory IgA
– Increased bacterial colonization
• Changes in lung parenchymal structure
– Unopposed enzymatic digestion
– Reduced production of surfactant
61
Protein-Energy Malnutrition
• Protein-energy malnutrition (PEM) has
adverse effects on respiratory musculature
and the immune response
• Primary PEM results from inadequate
intake of calories or protein or both
– Typically seen only in developing countries
• Secondary PEM is due to underlying
illness
– Illness may cause decreased caloric or
protein intake, increased nutrient losses, or
increased nutrient demands
Providing the Appropriate

Combination of Substrates
• Protein
– Approximately 20% of a patient’s estimated
caloric needs should be provided by protein
• Carbohydrate
– Total calories per day from carbohydrates
can range from 45% to 65%
• Fat
– The remaining calories (20% to 30%) should
be provided from fat
Routes of Feeding
• Enteral feeding
– Route of choice
– Safer, healthier, and easier than parenteral
route
– Potential complication of aspiration
• Parenteral feeding
– Done through peripheral or central vein
– Mechanical, infectious, and metabolic
complications have been reported
62
Pulmonary Patient
• COPD, Asthma, and CF
– Perform a complete nutrition assessment
– Evaluate energy needs and provide an
appropriate amount (do not overfeed or
underfeed)
– Ensure protein balance
– Monitor fluids and electrolytes, especially
phosphorus
– Evaluate vitamin and mineral status as
indicated
Pulmonary Function
• Protein malnutrition has been linked to

reduced function of the diaphragm and
other muscles of breathing.
• This leads to a reduced vital capacity

and PIP.
• Represents a significant problem in the

ICU when trying to wean the patient
from mechanical ventilation
188
Malnutrition
189
63
Cystic Fibrosis
• Patients have decreased intake and

increased metabolic needs BUT
• IF patients attempt to eat well the pancreas

insufficiency causes malabsorption for
nutrient needs
190
64

Assessment of The Patient

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Assessment of The Patient

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Assessment of The

• List The Factors That Influence

• Define The Difference Between Objective

• Identify Normal And Abnormal Breathing

• List The Normal Values of a CBC

• List The Normal Values of a Chemistry

• List The Pathogens Found During Culture

• List The Normal Values For an Arterial

• List The Common Views And The

• List The Normal Parts of an ECG Wave

• Explain The Need for Nutritional

Where can we find this information? Chart Review

• Chief Complaint (CC)

• History of Present Illness (HPI)

• Past Medical History

• Social And Environmental History

• Activities of Daily Living

• To obtain essential diagnostic information

• To help monitor changes in the patient’s symptoms

Guidelines (Box 15-1)

Establish a professional role during introduction

Guidelines (Box 15-1)

Common questions to ask for each symptom

• How severe is it?

• Where on the body is it?

• What seems to make it better or worse?

• Has it occurred before?

Open ended questions: encourage patients to describe

Closed Questions: focus on specific information and provide

Indirect Questions: are less threatening than direct questions.

• Orthopnea: dyspnea in the reclining position;

• Platypnea: dyspnea when moved to the upright

Breathlessness: unpleasant urge to breathe.

– Pay attention to whether patient can speak in

Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,2

Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,2

Cardiopulmonary Symptoms (cont.)

• Sputum that has pus cells in it is said to be “purulent.”

• Sputum that is foul smelling is “fetid.”

• Recent changes in the color, viscosity, or quantity of

Cardiopulmonary Symptoms (cont.)

Pack years (cont.)

30 cigarettes / 20 cigarettes per pack = 1.5 packs

15 cigarettes / 20 cigarettes per pack = 0.75 packs

65 year-old female states that she has been smoking for

Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,3

Essential for evaluating patient’s problem

Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,4

Done during first few seconds of patient encounter,

Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,4

• Sensorium: Level of consciousness and

Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977,4

• Easy to obtain and provide useful information

• The vital signs (VS) are easy to obtain and

• Vital Signs = RR, HR, BT, BP

• Normal: 98.6 oF or 37.0 oC

• Decreased temperature: Hypothermia (cold exposure)

• Can be measured at: mouth, axilla, ear or rectum

Heart Rate (HR)

• Evaluate rate, rhythm and strength

• Tachycardia: HR>100 beats/min.

• Bradycardia: HR<60 beats/min

• Measure for full minute if pulse is irregular