Respiratory Assessment

• Respiratory assessment is performed as part of a physical examination or if a patient presents with respiratory problems (dyspnea, cough, chest pain) or a history suggesting lung pathology.

Considerations Before Assessment

• Ensure the patient sits upright with hands at their sides
• When examining the patient's back, ask them to move their arms forward and hug themselves to move the scapulae away from the upper lung fields.
• Ensure adequate lighting
• Expose the chest fully while minimizing exposure time
• Ensure a quiet room

Chest Patient Assessment Categories

• Subjective assessment involves patient interviews with open–ended questions about signs and symptoms related to chest cases like dyspnea, cough, chest pain, wheezing, sputum, and hemoptysis.
• Objective assessment includes general and local examinations.

Subjective Assessment Details

• The personal history included is to enable the therapist to be familiar with the patient's name.
• Age may be relevant, as infantile patients may have cystic fibrosis or bronchial asthma and young patients may have chronic bronchitis or TB due to malnutrition.
• Conditions like senile emphysema or cor pulmonale can occur in old age patients.

Personal History Checklist

• Determine the patient's sex, occupation, and habits such as smoking or alcoholism.
• Record the patient's address and floor of residence, as some diseases like black lung diseases are related to location and humidity is higher on the first floor.

Medical History Questions

• Record past medical history of diseases like diabetes mellitus, hypertension, or rib fractures
• Document surgeries like lung resection, open heart surgeries, or thoracic surgeries
• Note patient medications, especially diuretics and antihypertensives

Present History Documentation

• Record the patient's chief complaint in their own words and note:
• Onset (sudden or gradual)
• Course (progressive, regressive, stationary, remission, or relapse)
• Duration (when the complaint first appeared)
• Document any family history of diseases like Hypertension/ Diabetes Mellitus or any family genetic disease.

Types of Assessment

• Decubitus refers to the patient's position:
• Sitting with leaning forward and supporting upper limbs is common in asthmatic patients.
• Long sitting lying, as in orthopnea.
• Side-lying in patients with unilateral diseases (lie on affected side for pleurisy or pneumonia) or lie on the healthy side with a rib fracture or herpes zoster to decrease pain.

Body Build Considerations

• Obese patients may have COPD (bronchitic type or blue bloater), or Diabetes Mellitus type 2
• Thin or cachectic patients may have chronic disease like COPD (emphysematic type or pink puffer), thyrotoxicosis, or malignancy.

Additional Observations

• Note if the patient is diaphoretic (sign of fear, pain, or anxiety), and observe their gait, odor, and emotional state.
• Face - Note if the patient is pale (anemic), has a moon face (Cushing syndrome), or has features of Down's Syndrome (Mangolism), which is a congenital disease

Eyes Considerations

• Red fissures of the sclera indicate chronic cough or chronic hypertension.
• Yellow sclera indicates jaundice.

Conjunctiva Observations

• Blue discoloration indicates cyanosis.
• Subconjunctival hemorrhage occurs in whooping cough.

Eyelid Examinations

• Buffiny indicates liver cirrhosis or chronic cough.
• Black color under the eyes indicates anemia.

Examination of the Mouth

• Cyanosed (blue) lips indicate central cyanosis.
• Red lips may indicate fever.
• Pursed lip breathing is a sign of COPD.

Neck Examinations

• A short and thick neck size can indicate obesity or lung emphysema.
• Normally, neck veins (jugular vein) are just visible.
• Abnormally congested and pulsating jugular veins indicate congestive heart failure or right-side heart failure.
• Spasms in the muscles of the neck may indicate the patient is using accessory muscles of breathing due to dyspnea.
• Pulsating neck indicates fever or aortic regurgitation
• Examine thyroid gland for normal or abnormal enlargement.
• Note Scars or Lymph nodes

Level of Consciousness

• Assess the patient's level of consciousness: conscious, semi-conscious, just alert, or comatose.

Record Vital Signs

• Temperature (normal 36.5 – 37.5)
• Blood pressure: normal is 100-140 systole/60-90 diastole
• Blood pressure should be measured from both limbs
• Heart rate: normal is 60-90 beats/min, with an average of 72 beats/min

Heart rate considerations

• Record heart rate's rate, rhythm, volume, force, and equality
• Asses different areas and from both limbs
• Respiratory rate: normal is 12-20 breaths/minute
• Respiration rates should be rated for rate, rhythm, depth, pattern, and character
• Oxygen saturation by pulse oximetry: normal is 95-100%
• Pain Index measured by VAS (0-10 scale) to compare and track improvement.

Extremities - Looking for:

• Collection of fluid is initially seen around the ankle and feet
• The skin appears stretched and shiny and pits on pressure
• Indicates fluid overload in the circulatory system due to low albumin level in blood, defective venous or lymphatic drainage, prolonged steroid use or chronic renal failure
• Excess fluid in blood means sustained cardiac overload and finally cardiac failure
• May be unilateral or bilateral, pitting or non-pitting.
• A test is to identify edema and its type

Edema Examination

• Apply pressure to the patient's bony prominence of the patient body for a few seconds or up to one minute, then release
• See the time the skin fold returns to its previous state before pressure.
• If prolonged time taken to return to the previous state edema is fluid (pitting).
• If it takes a short time to return to previous state, edema is a protein (non-pitting).
• Peripheral edema suggests ventricular failure or lymphatic dysfunction.

Cyanosis Inspection

• Bluish color of the skin or mucous membranes caused by chronic hypoxemia in peripheral cyanosis.
• The degree of blueness is proportional to carboxyhemoglobin percentage
• An anemic patient needs to be significantly hypoxic to be cyanosed
• A polycythemic patient will turn blue even if slightly hypoxic.
• Peripheral cyanosis indicates low cardiac output.
• Central cyanosis is inadequate gas exchange in the lungs.

Additional Extremity Checks

• Temperature by feeling hotness or coldness.
• Clubbing fingers should be assessed for: bulbous shape, and loss of angle between the nail and nail-bed, seen in fingertips and toes

Clubbing Fingers Information

• Exact cause is unknown, but its a finding in cardiac or pulmonary conditions causing chronic hypoxia
• It is defined as the obliteration of the angle of the nail bed
• It has various grades including just obliteration of the nail bed

Clubbing Finger Grades

• Just obliteration of the angle of nails bed (reversible)
• Parrot peak appearance (reversible)
• Drumstick appearance (reversible)
• Pulmonary osteoarthropathy with enlargement of the distal ends of long bones (irreversible).

Clubbing Finger Test - The Schamroth window test

• Clubbing finger tests are named clubbing finger test, diamond test, window test.
• Observe Dyspnea for awareness (difficulty) of respiration rate, rhythm, or depth.
• Note Cough (dry or productive), which is a protective mechanism to expel inhaled particles.
• Record expectoration color and consistency as to passage of sputum out of the respiratory tract
• Look for Hemoptysis or expectoration of blood originating from below the vocal cords
• Enquire about Chest pain

Types of Objective Assessments

• Inspection involves visual examination, without touching the patient.
• Palpation is the act of touching the patient.
• Percussion entails tapping on the patient.
• Auscultation means listening to the patient's body sounds.

I-Inspection Details

• Inspection involves observing things you can see with the eyes
• Look at the skin shape of the chest, and the movement of respiration

General Skin Observations

• Skin should be visually inspected for nodules, scars, incisions, ulcers, hematomas and alterations in color.
• Note the Enlargement of axillary lymph nodes, subcutaneous emphysema, vascular spiders, and any prominent blood vessels.
• Look for discharge sinuses or lesions on the breast.

Basic Shape Observations

• Chest symmetry, transverse, anteroposterior, and vertical diameters need to be observed
• Transverse Diameter - Width of the ribs measured from anterior or posterior
• Anteroposterior sternum - Distance from the vertebra behind
• Vertical - The measurement from the diaphragm up to the highest point on the chest
• All diameters increase with inspiration

Normal Chest Sizing

• Anteroposterior to transverse diameter ratio is normally 1:2.
• Ribs should run diagonally downwards and laterally.
• The costal angle should be 90 degrees.

Chest Shape Abnormality Considerations

• Kyphosis (increased thoracic spine curvature) can impact lung space
• Restriction greatly impacts breathing than only Kyphosis
• Kyphoscoliosis (thoracic spine curvature and lateral bending) can impact breathing abilities
• Kyphosis is curvature of the spine, anterior-posterior
• Scoliosis is curvature of the spine from side to side

Chest - Abnormalities

• General Abnormalities are Barrel Chest:
• AP diameter = Transverse diameter.
• Ribs & Interspaces are wider and more horizontal
• Subcostal angle increased
• Raised shoulder.
• Example: COPD emphysema

Chest Abnormalities

• Flat (alar) Chest:
• AP decreases.
• Scapula is winged, ribs are oblique, and interspaces are narrowed.
• Example: pulmonary TB.
• Funnel chest/pectus excavatum: the lower part of the sternum goes inwards.

Funnel Chest

• AP diameter affected as well as lung volume.
• May be congenital or caused by occupational causes, like those of a shoe maker.
• All previous chest deformities lead to hypoventilation.
• Pigeon chest/pectus carniatum: AP>transverse

Local Chest Aberations

• Local abnormalities affects one side of the chest.
• Retraction (due to): Fibrosis: pleural thickening after pleural effusion, lung abscess, TB
• Collapse: intrabronchial obstruction
• Bulging is caused in the chest wall by : Subcutaneous emphysema, Edema and inflammations such as tumors
• Bulging in the pleura can happen with: Tense pleural effusion, Empyema. Tension pneumothorax, Pleural tumors
• Bulging in the lung: Apical bronchial carcinoma & Obstructive emphysema

Rate

• Normal adult rate: 12-20 breath/min
• In infants: 30-60 breaths/min.
• In the elderly: Rate maybe increased RR
• Tachypnea (increased RR) may be caused by exertion, fever, hypoxia, or pain
• Bradypnea may be caused by hypothermia or medication
• Abnormalities in breathing patterns may indicate the severity of disease.

Rhythm

• Rhythm should be regular; inspiration should have a shorter span than expiration
• The ratio between inspirations to expiration (I:E) is 1:2
• COPD can be a likely cause of prolonged expiration.

Depth

• Depth may be shallow or deep but normally is between.
• Nose breathing and mouth breathing

Modes

• Abdominothoracic breathing is normal in males because of the well developed diaphragm
• If abdominothoracic breathing is observed in females, consider chest conditions like rib fracture,nerve issue (neuralgia, myositis, pleural, paralysis and pain), COPD

Thoracoabdominal Breathing

• Natural in females because of uterus
• If observed in males, consider problems such as abdominal pain, phrenic, or ascites/distension

Accessory Muscles Factors

• Normally 75% of working lies on the diaphragm and accessory muscles
• Use of upper and middle fibers of trapezius, Sternocleidomastoid, Scalene muscle, Pectorals major, Serratus anterior is a sign of abnormal breathing

Palpatory Steps

• Palpate skin and tissue, noting crackling or paper-like feel (pulmonary leak), trachea shifts, distance from cricoid to sternum, tenderness (localized), quality of breaths, and vocal vibrations.
• Normally, 70% of work relies on diaphragm

Palpation: A- Tracheal Shift

• Normally trachea is centrally positioned as the distance between trachea & SCM equal in both sides
• Patient should sit erect with a semi-flexed head
• Doctor usese index fingers then introduce it in the sternal notch between trachea & SCM in one side. Compare the other side.
• Do not apply to same sides at same time

Tracheal Shift Causes

• Compression is trachea being pushed from one side, as in space occupying mass or lesion
• Attraction means trachea is being pulled to one side.

Lower Down Inspections

• Note the level of the heart by palpating the apex.
• To determine hyperventilation, measure Crico/ sternal distance. - Measure upper cartilage - Locate cricoid cartilage below thyroid cartilage, then put fingertips in between
• Normal is 3 fingers betwixt coracoid and sternum, if less, is hyperventilation as in COPD
• During inspiration, trachea will visually descend

Localized Tenderness Examples

• If localized with sternum then leukemia
• If over ribs, then ribs fracture tumors and/or intercostal spaces, then neuralgia,pleurisy emphysema
• If intercostal spaces, the myalgia

Auscultation Examples

• Ronchi in bronchitis
• Rub in pleurisy

Chest Expansion Assessment

• Judge chest movement - It should be assessed based upon quality, symmetry and depth of the body
• Should be equal when the area is free.
• Decreases will happen with pneumothorax; unilateral may be pneumonia
• When bilateral, the COPD/asthma
• To assess, put hands out like a fan, by directing towards the midline.
• The following are types of chest expansion

Apical

• Apical chest expansion: (1-2 cm): Palm on chest and fingers on rest under clavicle to the notch of sternum

Sternum

• Fingers should be under auxilla: fingers towards the angle of mandibular sternum.

General

• Fingers directed outwards
• Palms level with nipple
• Thumb directed medially
• Hands toward xyphoid process, fingers interlocked, and directed posterior and basal on patients

Tactile Details

• Feel for normal vibration by vocal (TVF)
• Vocal cords vibrations on chest when patient speaks
• Sounds transmits to trachea and chest when asking to be 99 in any type of language
• Normal transmits are easily heard when in solid and poorly in air
• Increase is heard in pneumona
• Decreases are common in emphysema and fiberosis

Chest Sounds

• Percussion;
• By tapping chest, sounds and vibrations with DIP joint on top
• Apply the above and from top to avoid areas such above and around the scapula
• If you are over, make sure to measure, location, quality to hear percussion.

Percussive Notes

• Normally should be resonant on percuss
• Flat will sound over the heart
• Decreased will sound mass or pleural
• Resonance sounds increased over stomach

Testing Positions

• A patient must take a tidal when testing, as the movement makes this.
• It’s performed to test the movement
• Take it from top to bottom to find the place to pull

Percussive Measurement Standards

• Should be 3.2 cm up to 7.8 in athletes
• Usually, the place is much higher to right do to position of liver.
• Less will cause many problems
• Should be with pneumonia

Lungs

• The bare area is the most tested
• The right side tends to have this area as an abnormality
• From the space can make the area larger

Listening Details

• Area not over and covered between from number 4 to 6
• If has air, the lung is inflated; otherwise, the areas should sound the dummest when they are normal.
• Listen for resonant.
• Must be a special area.
• Should know location.

Isthmus

• Apex of lung
• Comes between three locations or body parts
• Must be medial to alter and lateral to have an anterior
• Lateral causes hyper lung.

Sound

• Auscultation
• To listening sound that comes from the body
• Can chest by Stethescope.

Body Sound Standards

• Make sure is easy to hear, good in equality, has adventitious
• Make sure you hear with sounds the volumes towards area that are to be test

Sound and Sounds

• Must be able to hear the trachea
• There three sound to know, Bronchial will go the heart
• -Bronchovesicular sounds
• Vesicular.
• Needs quite environment
• Ask breathe mouth while turning the face different way
• Be sure to be able measure sound side to when and compare symmetry.

Placement of Stethoscope

• When placing the stethoscope for auscaltion anterior
• Focus on areas like Chest and Upper bones
• When placing it posterior, the bones and muscles must be near to hear.
• Can hear, A and B
• Normal and abnormal
• Can reduce and prevent air entering
• Sounds add and come