Idol pp voice
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Transcript of Idol pp voice
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RTH 112
Assessment
Unit 2
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Text Reference
• Egan 9th Edition– Chapter 15 “Bedside Assessment of the
Patient”
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Objectives• Write a brief summary explaining the importance
of conducting a patient interview in 500 words or less
• Without the use references, list the major components of a health history
• Using the notes, review the techniques to conduct a patient interview
• Without the use of references, summarize the importance of conducting a physical examination
• Verbally describe the four major examination techniques
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Patient Evaluation
• Initial Assessment– Clinical Manifestations
• Patient Interview
• Physical Examination
• Secondary Assessment– Diagnostic Studies
• Arterial Blood Gases
• Pulmonary Function Studies
• Chest Films
• Other Diagnostic Procedures as Indicated
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Patient Interview
• Determine Level of Consciousness– Normal: alert & cooperative– Lethargic– Confused– Obtunded: diminished cough or gag– Semi-comatose: responds to painful stimuli– Coma: unresponsive to pain
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Patient Interview
• Orientation of time, place and person– Well oriented, cooperative
• Able to follow simple commands
– Disoriented, confused– Inability to cooperate:
• Language difficulties• Influence of medications• Hearing loss• Fear, depression
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Patient Interview• Assess Emotional State
– Anxiety• Respiratory distress, hypoxemia
– Depression• Quiet or withdrawn, in denial
– Anger• Combative, irritable
– Euphoria• Influence of drugs
– Panic• Hypoxia, air hunger, status asthmaticus
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Patient Interview• Measure Subjective Symptoms
– Orthopnea• Difficulty breathing except in upright position
– General Malaise• Run down, nausea, weakness, fatigue
– Dyspnea• Feeling SOB
– Grade I: normal dyspnea after unusual tension– Grade II: breathless after going up hill or stairs– Grade III: dyspnea while walking at normal speed– Grade IV: dyspnea moving slowly & short distances– Grade V: dyspnea at rest, small tasks
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Patient Interview
• Pain– Location
– Quality (what kind is it)
– Severity
– Aggravating factors
– Relieving factors
– History (when did it start and how did it progress)
– Context (circumstances of onset)
– Accompanying Symptoms
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Patient Interview
• Symptoms of Nose and Throat– Nasal secretions
• Amount
• Irritants, allergies
– Itching or burning sensation of nose and throat– Dysphagia
• Difficulty swallowing
• Hoarseness
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Patient Interview
• History of present illness– Current medical/physical problems– Current meds, including herbs, etc.
• Past medical history– Previous medical problems, hospitalizations,
surgeries, drug allergies, etc
• Family history– Heart disease, diabetes, COPD, etc.
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Interview Techniques
• Ask open ended questions– No yes or no questions
• Communicate using simple language– KISS Method– Use pictures, diagrams– Interpreter for those with language barriers
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Physical Examination
• Begin with Assessment by Inspection– What Can You See?
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Assessment By Inspection
• General Appearance– Age– Height– Weight– Sex– Nourishment
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Assessment By Inspection
• Peripheral Edema– Presence of excessive fluid in the tissue– Pitting Edema– Occurs primarily in arms and ankles– Caused by CHF, Renal insufficiency/failure– Rated +1, +2, +3
• The higher the number, the greater the swelling
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Peripheral Edema
Abnormal buildup of fluid in the ankles, feet, and legs is called peripheral edema. Foot with Edmea Normal Foot
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Assessment By Inspection
• Clubbing of fingers– Suggestive of pulmonary disease– Caused by chronic hypoxia– Can affect thumb, fingers and toes– Condition is present when the angle of the nail
bed and skin increases
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Assessment By Inspection
• Venous Distention– Occurs with CHF– Seen in patients with obstructive lung disease– Seen during exhalation because of the
obstructive component
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Assessment By Inspection
• Capillary Refill– Quick check of perfusion– Blanching of hand or nail beds and watch for
blood return– Normally 3-5 seconds– Commonly performed for the Allen’s Test
before arterial blood gas puncture
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Assessment By Inspection
• Diaphoresis– State of perfuse/heavy sweating– Heart failure– Fever, infection– Anxiety, nervousness– Tuberculosis (night sweats)
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Assessment By Inspection
• Skin Color– Normal: pink– Abnormal: pale
• Due to anemia or blood loss
– Jaundice: yellow• Increase in bilirubin, mostly face & trunk
– Erythema: redness• Capillary congestion, inflammation, infection
– Cyanosis: blue/gray• Hypoxia (5 g of reduced hemoglobin)
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Assessment By Inspection• Chest Configuration
– Normal: A-P diameter• Straight spine, no alterations in chest size
– Pectus Carinatum• Anterior protrusion of the sternum
– Pectus Excavatum• Depression of the sternum
– Kyphosis• Hunchback or convex spine curve
– Scoliosis• Lateral curve of the spine
– Kyphoscoliosis: combination of both– Barrel Chest
• Increased A-P diameter resulting form air trapping
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Assessment By Inspection
• Movement of Chest/Diaphragm– Symmetrical movement– Unequal movement
• Chronic lung disease
• Atelectasis
• Pneumothorax
• Flail Chest – paradoxical
• Intubated with ET tube in one lung
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Assessment By Inspection• Breathing Patterns
– Eupnea – normal rate, depth, rhythm– Tachypnea- over 20 bpm
• Fever, hypoxia, pain, CNS problem
– Bradypnea- less than 8 bpm• Variable depth and irregular rhythm
– Apnea- cessation of breathing– Hyperpnea- increased rate & depth, regular
rhythm• Metabolic/CNS disorders
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Assessment By Inspection
• Breathing Patterns– Cheyne Stokes- gradual increasing the decreasing rate
and depth in a cycle with periods of apnea• Increased ICP, Meningitis, overdose
– Biots- increased rate and depth with irregular periods of apnea
• CNS problem
– Kussmauls- increased rate (>20) increased depth, irregular rhythm, seems labored
• Metabolic acidosis, renal failure, diabetic ketoacidosis
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Assessment By Inspection
• Breathing Patterns– Apneustic- prolonged gasping inspiration
followed by extremely short, insufficient expiration
• Problem with respiratory centers, trauma or tumor
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Assessment By Inspection
• Muscle use– These muscles are used to increase ventilation
during times of stress, increased airway resistance, etc.
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Assessment By Inspection
• Muscle Use
Muscles used during Normal Breathing – Diaphragm– External Intercostals– Exhalation is passive
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Assessment By Inspection
• Accessory Muscle Use– Used to increase ventilation
Muscles of normal ventilation PLUS• Intercostals, scalene, sternocleidomastoid, PLUS
• Abdominal muscles
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Assessment By Inspection• Retractions
– Chest moves inward during inspiration instead of outward
– Due to a blocked (obstructed airway)
– A sign of respiratory distress in infants
• Nasal Flaring– Flaring of the nostrils during inspiration
– A sign of respiratory distress in infants sometimes accompanied by grunting
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Assessment By Inspection
• Character of Cough– Strong, moderate, weak– Productive, nonproductive– Frequent, infrequent– Tight, moist
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Assessment By Palpation
• Pulse– Normal: 60-100– Tachycardia: >100– Bradycardia: <60– Adverse Reaction: >20 Increased HR– Monitor rhythm
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Assessment By Palpation
• Tracheal Deviation– Pulled toward pathology (inside lung)
• Atelectasis
• Pneumonectomy
• Diaphragmatic paralysis
– Pulled away from pathology (outside lung)• Massive pleural effusion
• Tension Pneumothorax
• Neck or thyroid mass
• Large mediastinal mass
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Assessment By Palpation
• Tactile Fremitus– Vibration felt by hand on the chest wall
• Vocal fremitus-voice vibrations on the chest wall
• Pleural rub fremitus – grating sensation due to roughened pleural surfaces rubbing together
• Rhonchial fremitus – secretions in the airway
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Assessment By Palpation
• Tenderness– Around suture sites, chest tubes, fractures
– Avoid areas of tenderness if possible
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Assessment By Palpation
• Chest Motion Symmetry– Hands placed on the patient’s chest move in
symmetry. If one hand moves more than the other, it indicates asymmetrical chest expansion
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Assessment By Percussion
• Performed by placing the middle finger between two ribs and tapping the middle finger’s first joint with the middle fingers of the opposite hand.– Resonance- normal air filled lung; hollow sound– Flat- over sternum, muscle or atelectasis; full sound– Dull-fluid filled organs; pleural effusion or pneumonia;
thudding sound– Tympany-air filled stomach; drum like sound– Hyperresonance-Areas of the lung with pneumothorax
or emphysema. Booming sound.
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Assessment By Auscultation
• Normal Breath Sounds- vesicular
– Bilateral vesicular: normal in both lungs– Bronchial vesicular: normal over the trachea or
bronchi
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Assessment By Auscultation• Increased, decreased, unequal or absent
– Always compare one lung with the other
– Egophany: “E” sound like “A”. Consolidation– Bronchophony & whispered pectoriloquy: increased
intensity of voice when spoken. Indicated consolidation and pneumonia
– An increase in voice indicates consolidation and pneumonia
– A decrease in voice indicates obstructed bronchi, pneumothorax, emphysema
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Assessment By Auscultation
• Abnormal Breath Sounds – adventitious– Rales (crackles)- fluid/secretions
• Coarse (rhonchi)- large airway secretions– Suction the pt/cough
• Medium– Pt needs CPT
• Fine (moist crepitant rales)- alveoli fluid– Pt has CHF/pulmonary edema
– PT needs IPPB, heart drugs, diuretics and oxygen
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Assessment By Auscultation
• Wheezes– Bronchospasm– Patient needs a bronchodilator– Unilateral wheezes indicative of FBO
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Assessment By Auscultation
• Stridor– Upper Airway Obstruction
• Supraglottic swelling (epiglottitis)• Subglottic swelling (croup, post extubation)• Foreign body aspiration
– Treatment• Topical decongestant (racemic epinephrine)• Suction/bronchoscopy • Intubation for severe swelling and epiglottitis
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Assessment By Auscultation
• Pleural Friction Rub– Caused by infection – A coarse grating or crunching sound– Inflamed visceral and parietal pleural surfaces
rubbing together– Associated with pleurisy, TB, pneumonia,
cancer, etc.– Treat with steroids, antibiotics as indicated
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Breath Sounds Review
http://Breath Sounds Review