Advanced Bedside Assessment PDF

Bedside Assessment of the Patient RC 1 M 3 Professor Barrette, MBA, RRT- ACCS, NPS, RPFT 1  Learning Objectives Describe why patient interviews are necessary and the appropriate techniques for conducting an interview. ...

Bedside Assessment of the Patient RC 1 M 3 Professor Barrette, MBA, RRT- ACCS, NPS, RPFT 1  Learning Objectives Describe why patient interviews are necessary and the appropriate techniques for conducting an interview. Differentiate between signs and symptoms. Identify abnormalities in lung function associated with common pulmonary symptoms. Identify breathing patterns associated with underlying pulmonary disease. Differentiate between dyspnea and breathlessness. Identify terms used to describe normal and abnormal lung sounds.  Learning Objectives (cont.) Describe the mechanisms responsible for normal and abnormal lung sounds. Explain why it is necessary to examine the precordium, abdomen, and extremities in a patient with cardiopulmonary disease. Describe some of the common abnormalities found during the exam of the precordium, abdomen, and extremities in patients with cardiopulmonary disease. Identify the three main tests used to diagnose coagulation disorders. Describe how the sputum Gram stain and culture are used to diagnose patients with pulmonary infections.  Learning Objectives (cont.) Describe what a critical value is and state its importance in clinical practice. Define the following terms related to clinical lab tests: leukocytosis, leukopenia, anemia, polycythemia, and thrombocytopenia. Identify which electrolyte disturbances interfere with normal respiratory function. Describe clinical tests used to identify cardiac stress and myocardial infarction.  Why Build Assessment Skills? Decisions regarding when to initiate, change, or discontinue therapy (tx) depend on accurate clinical assessments. RTs often play a vital role in clinical decision making and must therefore develop competent bedside assessment skills. RT must assume responsibility for gathering and interpreting relevant bedside patient data. 5 Why Build Assessment Skills? (cont.) Bedside assessment: 1. Process of interviewing and examining a patient for signs and symptoms of disease 2. Evaluating the effects of treatment Very often bedside assessment techniques provide initial evidence that something is wrong AND are of little risk to the patient 6 Why Build Assessment Skills? (cont.) Two key sources of patient data: The patient’s medical history Physical examination Data gathered during the initial patient interview and physical examination help identify the need for subsequent diagnostic tests. After a tentative diagnosis is made, these assessment skills are used repeatedly to monitor the patient’s response to therapy, monitor the patient’s response to therapy, and make any necessary adjustments. 7  Patient Assessment Life functions – getting O2 from the air to all the cells of the body (4) Critical Life Functions 1. Ventilation – moving air in and out of the lungs 2. Oxygenation – getting O2 into the blood 3. Circulation – moving the blood through the body 4. Perfusion – getting oxygen into the tissues/cells  Patient Assessment (Cont.) We measure these (4) life functions in many ways, one of which is using vital signs Ventilation – RR, VT, Chest Movement, Breath sounds, PaCO2 , ETCO2 Oxygenation – HR, Color, Sensorium, PaO2 , SpO2 Circulation – HR and strength, cardiac output Perfusion – BP, sensorium, temperature, urine output, hemodynamics Assessment and treatment should be based on life functions because almost every part of assessment relates to one of these 4 life functions  Patient Assessment (Cont.) If assessment of the life functions identifies problems, they must be treated or corrected right away If any of these life functions are absent (i.e., no breathing, no pulse, no blood pressure) then there is an emergency, which may require resuscitation When there is an emergency: 1. 1st priority is ventilation* 2. 2nd priority is oxygenation 3. 3rd priority is circulation 4. 4th priority is perfusion The most common problem is with oxygenation  Basic Terminology Diagnosis (Dx:) is the process of identifying the nature and cause of illness A disciplined, systematic approach based on careful history taking, physical examination, and testing (primarily performed by a physician) Differential diagnosis (Diff Dx:) is the term used when signs and symptoms are shared by many diseases and the exact cause is unclear (i.e., cough) Is the list of all possible causes of a sign or symptom Signs refer to the objective manifestation of illness (i.e., increased RR, HR, BP) Symptoms refer to the sensation or subjective experience of some aspect of an illness Symptoms must always be stated by the patient and NEVER assumed from observed signs. 11  Basic Terminology (cont.) Chief Complaint (CC) – is a concise statement by the patient or family member relating to his/her reason for seeking medical attention. “Why are you here?” or “What medical problem brought you to the hospital?” The patient’s primary symptom described in his/her OWN words! Identification of the CC is the 1st step in determining the admitting diagnosis. Provides a starting point with which to guide the patient history, physical, and diagnostic testing. 12  Basic Terminology (cont.) History of the present illness (HPI) – is a detailed description of the symptoms, chronology of events, and resultant impact on the patient’s health Each symptom is fully described in terms of the nature of the symptom, its location, and its severity Rule out (R/O) - means to eliminate as a possibility. (i.e., a doctor may have a patient's blood pressure tested to rule out high blood pressure. That is, the doctor wants to know if the results from the test will eliminate the possibility that the patient has high blood pressure. Status post (S/P) - “condition after” means that the client has had the procedure or event in the past. (s/p appendectomy) 13 14  Interviewing Interviewing for Cardiopulmonary Symptoms: Dyspnea Cough Sputum production Chest pain Fever and/or sweating Pedal edema Syncope (dizziness and fainting) - temporary loss of consciousness caused by reduced blood flow and therefore a reduced supply of oxygen and nutrients to the brain.  Common Cardiopulmonary Symptoms Dyspnea Sensation of breathing discomfort by patient (subjective feeling) Cannot be inferred from observing a pt.’s breathing pattern Most important symptom RT is called upon to assess and treat Often perceived as life-threatening and may provoke a profound sense of dread During the interview, RT should pay attention to whether or not the patient can speak in full sentences Pt.’s with severe dyspnea often cannot speak more than a few words at a time If this is the case, interview should be condensed and treatment initiated ASAP When possible, questions should be brief and limited to yes or no responses in severe dyspnea Quality and intensity of dyspnea? Onset? Duration? 16  Common Cardiopulmonary Symptoms (cont.) Dyspnea (cont.) Thought to be derived from the interaction of various physiological, psychological, social, and environmental factors. Underlying cause may be pulmonary, cardiac, hematologic, neurologic, psychogenic, metabolic, or mechanical. Treatment should be aimed at the underlying cause Pt.’s may describe as an increased WOB, chest tightness, or “air hunger” “I feel short of breath.” “I’m having difficulty breathing.” “I can’t catch my breath.” 17  Common Cardiopulmonary Symptoms Dyspnea cont. 3 complex factors influence the perception of breathing: 1. The neural drive to breathe coming from the respiratory centers in the brain 2. Tension developed in the respiratory muscles 3. The corresponding displacement of the lungs and chest wall When the neuronal signals in charge of these sensations become unbalanced, breathing is perceived to be abnormal.  Psychogenic Dyspnea When a patient with normal cardiopulmonary function complains of dyspnea or suffocation it is referred to as psychogenic hyperventilation syndrome. Normally associated with panic disorders and anxiety. Resultant hyperventilation (low CO2 ) mat present alongside chest pain, anxiety, palpitations, and paresthesia. Can be sporadic or chronic and is self-  Treatment of Dyspnea RT must ALWAYS approach any situation involving hyperventilation or dyspnea as if it had a pathogenic basis! 1st priority is to measure vital signs, including SaO2/SpO2 , 12-lead ECG, arterial blood gas (abg). A psychogenic source is to be considered only AFTER a pathogenic source has been ruled out.  Common Cardiopulmonary Symptoms Breathlessness Sensation of unpleasant urge to breathe Can be triggered by acute hypercapnia, acidosis, or hypoxemia Is believed to be the conscious perception of intense neural discharge from the brainstem to the respiratory muscles Anxiety is often accompanied by breathlessness and hyperventilation. 21  Positional Dyspnea Orthopnea: dyspnea that is triggered when the patient assumes the reclining position Common in patients with CHF, mitral valve disease, and superior vena cava syndrome Platypnea: dyspnea triggered by assuming the upright position Typically occurs in patients following pneumonectomy and in those with chronic liver disease Sometimes observed during hypovolemia and in some neurologic diseases.  Positional Dyspnea (Cont.) Orthodeoxia: oxygen desaturation on assuming an upright position. Accompanies platypnea Trepopnea: when lying on one side relieves dyspnea Usually associated with either CHF or pleural effusion. 23  Language of Dyspnea RT should try to categorize each sensation according to a particular aspect of breathing: inspiration, expiration, respiratory drive, or lung volume Ask patient about quality and characteristics of dyspnea Patients with cardiopulmonary disease frequently experience several unpleasant breathing sensations simultaneously Different lung diseases evoke different sensations (i.e., asthma vs interstitial lung disease) 24  Intensity of Dyspnea These scales are used to document the patient’s perceived intensity of dyspnea, as well as provide a way to assess the patient’s response to treatment over time 25  Common Cardiopulmonary Symptoms (cont’d) 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. Cough history: Onset and duration Characteristics Time of day (i.e., day or night) Frequency Dry vs. Loose; productive or non-productive Acute vs. Chronic; weak or strong A chronic cough is one lasting 8 weeks or longer  Common Causes of Chronic Cough Upper airway cough syndrome (UACS)* Asthma* Gastroesophageal reflux disease (GERD)* Chronic bronchitis associated with cigarette smoking ACE-1 Cough * Restrictive diseases may result in dry, nonproductive coughs (i.e., pulmonary fibrosis, CHF) *Obstructive diseases may result in loose, productive coughs (i.e., CBABE) 27 Less Common Causes of Chronic Cough 28  Basic Terminology Phlegm - Mucus from tracheobronchial tree not contaminated by oral secretions Sputum - Mucus from lower airways that passes through the mouth as it is expectorated Fetid - Foul-smelling sputum; associated with long-term infections i.e., bronchiectasis, lung abscess, CF, aspiration, pseudomonas Purulent – sputum that contains WBCs (thick, colored, and sticky) Sputum purulence occurs when inflammatory or sloughed (dead tissue) mucosal epithelial cells are present (i.e., viral or bacterial infection) Mucopurulent sputum – thicker, white, or yellow in color and sticky Mucoid – clear and thick (i.e., asthma) 29  Common Cardiopulmonary Symptoms (cont.)  Sputum Excessive sputum production is generally associated with acute or chronic infection or inflammation of the respiratory mucosa. (Common in pulmonary disease) Respiratory care clinician should directly observe and record the appearance and characteristics of sputum produced: often signs of infection and must be documented and reported to the physician Amount (quantity i.e., tsp (5mL), tbsp. (15 mL)., or portion of a cup) Color – (i.e., clear, cream, white, yellow-green, rust, yellow, red, and brown) – cellular debris and WBCs can affect sputum color Consistency (viscosity) – partly a function of the sputum’s water content Odor  Common Cardiopulmonary Symptoms (cont.) Hemoptysis Coughing up blood or blood-streaked sputum from the lungs Blood-tinged sputum is associated with a large number of pulmonary disorders Massive (Frank) More than 300 ml of blood expectorated over 24 hours Common causes: bronchiectasis, lung abscess, and acute or chronic tuberculosis 31. 32 Common Cardiopulmonary Symptoms (cont.)  Chest Pain Location Description Chest wall Pleuritic Non-pleuritic 33  Chest pain Pleuritic chest pain—located laterally or posteriorly Sharp, and increases with deep breathing (i.e., pneumonia and pulmonary embolism) Usually described as a sharp, stabbing type of pain 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 (pressure sensation with exertion or stress that results from CAD), gastroesophageal reflux, esophageal spasm, chest wall pain, and gall bladder disease Usually described as a dull ache or pressure type of pain 34  Fever Fever is an elevated body temp >38.3 o C (101o F) Normal temp for adults: Oral: 97.6-99.6 degrees F or 36.5-37.5 degrees C Rectal: 98.7-100.5 degrees F or 37.1-38.1 degrees C Axillary: 96.7-98.5 degrees F or 35.9-36.9 degrees C Tympanic: similar to rectal Temperature elevation caused by disease is called fever and the patient is said to be febrile 35  Fever (cont.) Fever and/or Sweating (>38.3 C; 101°F) Increases metabolic rate, O2 consumption, CO2 production – Clinical presentation: Diaphoresis Hot sweats Night sweats Cold sweats 36  Fever (cont.) Fever with illness of at least 3 weeks duration: temperatures > 38.3°C (101°F), and no diagnosis reached following three or more clinic visits or three or more days in the hospital is the definition of fever of unknown origin (FUO). 37  Hypothermia Body temperature normally decreases at night and normal values may be as low as 35.0° C (95.0° F) during sleep. Hypothermia can and most commonly occurs due to exposure to environmental cold. Reduces the metabolic rate and tissue demand for oxygen. Because of the reduction in metabolic rate, hypothermic patients may exhibit slowed or shallow breathing. When hypothermia is observed due to non-environmental causes, the clinician should suspect involvement of the hypothalamus. Low body temperature should alert the clinician to a possibly significant neurological incident, such as head trauma, stroke, or evolution of a mass.  Pain  Patients with cardiopulmonary disease may experience generalized pain and discomfort or localized pain due to specific injury or disease. Chest pain is a common symptom in patients with a wide variety of cardiopulmonary problems ranging from heart disease to pneumonia, pleurisy, rib fracture, pneumothorax, and tumor. Abdominal pain can be caused by many different disease states and conditions including gastric or intestinal disease, reflux disease, appendicitis, and diverticulitis. Acute, intense abdominal pain with hemodynamic instability represents a medical emergency requiring immediate attention.  Pain (cont.)  A common method is to ask the patient to rate his or her pain on a scale of 0 to 10, where 0 indicates no pain and 10 indicates the worst possible pain. In patients who are semiconscious, unconscious, or unable to otherwise communicate, the presence of the physical signs of pain should be noted: Grimacing Writhing Tachycardia Hypertension Tachypnea Diaphoresis Piloerection 40 Critical Care Pain Observation Tool (CPOT) The CPOT is based on observation of the patient’s facial expression, body movements, muscle tension, and compliance with the ventilator for intubated patients or vocalization for extubated patients. Total CPOT scores range from 0 to 8. 41  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  Venous congestion is caused by the heart’s reduced ability to effectively pump blood. The increased hydrostatic pressure from blood pooling in gravity- dependent lower extremities causes fluid to leak into the interstitial spaces. Patients with chronic hypoxemic lung disease usually develop right heart failure (cor pulmonale) due to pulmonary hypertension 43 Pedal Edema (cont’d) Can be classified from 1-4 depending on severity ”1” = trace of heart failure with rapid refill “4” = severe pitting with refill time > 2 minutes 44  Syncope A temporary loss of consciousness caused by reduced blood flow Reduction in blood flow leads to a reduced supply of oxygen and nutrients to the brain Reduced cerebral blood flow may be localized or generalized 45  Common causes of syncope Drugs Valsalva maneuver Prolonged coughing Hypoxia Hypocapnia Vasovagal (most common) Results from a loss of peripheral venous tone Physical/emotional stress, pain, venipuncture, prolonged standing, anxiety The vagus nerve is the longest cranial nerve. It contains motor and sensory fibers and, because it passes through the neck and thorax to the abdomen, has the widest distribution in the body. 46  Height and Weight (BMI) (18.5-24.9) In adult patients, clinicians typically utilize the height and weight measurements to calculate Body Mass Index (BMI). BMI is a way of measuring a person’s weight relative to his or her height Allows healthcare professional to discuss a pt.’s weight objectively on a standardized scale Helpful for risk stratification for a variety of chronic and acute disease processes. Overweight or obese patients are at risk for the development of heart disease, high blood pressure, stroke, cancer, osteoarthritis, sleep apnea, and diabetes. 47  BMI = Weight(lb)/[Height (in)]2 X 703) ht or obese patients are at risk for the development of heart disease, high blood pressure, stroke osteoarthritis, sleep apnea, and diabetes. 48  Format for Obtaining a Medical History Chart review Review of patient’s chart for current medical problems Chief Complaint (CC)/History of present illness (HPI) – explains current medical problems Review past medical history (i.e., pack years, advance directives) (i.e., DNR, DNI) - information in the patient’s medical record indicating any limits on the extent of care to be provided in the event of cardiac or respiratory arrest Review family, social/environmental history Review systems Patient interview Physician and nursing consultations Objective: Take the time to know your patients!!!  The Physical Examination Essential for evaluating patient’s problem and determining ongoing effects of therapy 50  Introduction to the Physical Exam RCP must be able to integrate the results of the patient history, physical examination, and diagnostic tests in confirming the diagnosis and creating an effective treatment plan. Accurate and effective physical exam is completed using an organized and systematic approach by body system, which may include: Vital signs, skin, HEENT, neck, back and spine, heart and blood vessels, thorax and lungs Abdomen/GI, extremities, musculoskeletal, neurologic 51  General Appearance Done during first few seconds of patient encounter If pt.'s general appearance indicates an acute condition, examination may be postponed until condition stabilizes. Indicators to assess pt.’s overall appearance: Level of consciousness Facial expression (i.e., pain, anxiety) Level of anxiety or distress Body positioning (i.e., tripodding – pulmonary hyperinflation) Personal hygiene 52  General Appearance Cachexia (cachetic)/Emaciated: Weakness and emaciation are are signs of general ill health and malnutrition Patients with prolonged illnesses may have severe weight loss and muscle wasting. Common chronic illnesses that are associated with cachexia are: congestive heart failure, chronic respiratory illnesses, such as COPD; and chronic renal failure. Diaphoresis (Diaphoretic): (Sweating) can indicate fever, pain, increased metabolism, or increased anxiety. The respiratory clinician should note the patient’s color and if the patient is sweating excessively. 53  Level of Consciousness Sensorium: term used when evaluating a patient’s cognitive functioning and orientation to time, place, person, and situation (i.e., oriented × 4) Is the patient aware of his/her current circumstances? Reflects oxygenation status of brain Affected by poor cerebral blood flow (hypotension) If patient NOT alert—standard rating scale is used to objectively describe patient’s level of consciousness 54  Level of Consciousness Rating Scales Confused Exhibits slight decrease of consciousness Slow mental responses Decreased or dulled perception Incoherent thoughts Delirious Easily agitated; irritable; exhibits hallucinations Lethargic Sleepy; arouses easily; responds appropriately when aroused 55  Level of Consciousness (cont’d) Obtunded Awakens with difficulty Responds appropriately when aroused Stuporous Does not awaken completely Decreased mental & physical activity Responsive to pain Responds slowly to verbal stimuli Semi-comatose Patient responds only to pain. 56  Level of Consciousness (cont’d) Comatose Unconscious Does not respond to stimuli Does not move voluntarily Exhibits possible signs of upper motor neuron dysfunction (i.e., Babinski reflex) Loses reflexes with deep or prolonged coma 57  Level of Consciousness (Scales) A number of scales and scoring systems have been developed to quantify level of consciousness or levels of sedation. The Glasgow Coma Scale ranges from 3 points (brain death) to 15 points (fully conscious). Both the Ramsay Sedation Scale and the Richmond Agitation Sedation Scale (RASS) have been developed to rate patients’ agitation and level of sedation. 58 Level of Consciousness (GCS) Mild impairment: 13-15 Moderate impairment: 9-12 Severe impairment: ≤ 8 (coma) GCS 4 cm above sternal angle Most common cause is cor pulmonale (i.e., chronic hypoxemia) 75 Physical Examination 76  JVP may increase due to right heart failure (e.g., cor pulmonale), left heart failure, constrictive pericarditis, pleural effusion, obstructed vena cava, and other cardiopulmonary disorders. 77 JVD 78 Examination of the Extremities Clubbing Capillary refill Cyanosis Pedal edema 79  Clubbing Painless enlargement of the terminal phalanges of the fingers and toes Angle of the fingernail to the nail base increases and the base of the nail feels “spongy” Causes: lung disease, various cancers, congenital heart disease, bronchiectasis, chronic liver disease, inflammatory bowel disease 80  Examination of Extremities COPD alone, even when hypoxemia is present, does not lead to clubbing. Clubbing of the digits in a patient with COPD indicates that something other than obstructive lung disease is occurring. 81  Capillary Refill Assessed by pressing briefly and firmly on the patient’s fingernail until the nail bed is blanched. When pressure is released, the speed at which the blood flow and color return should be 2 seconds or less. Decreased C.O. and poor digital perfusion = slow capillary refill (>2 seconds) 82  Lung and Chest Topography Surface Landmarks/ Imaginary Lines Used to describe an anatomic region of the chest Anterior Midsternal line – located in the middle of the sternum and equally divides anterior chest into left/right hemithoraces. Midclavicular line (left and right) – run parallel to the sternum, traditionally down through the male nipple. 83 Lung and Chest Topography (cont.) Posterior Midspinal (Vertebral) line – runs along spinous processes of the vertebrae Scapular lines (left and right) - runs through the middle of either the left or right scapula, parallel to the vertebral line Lateral Anterior axillary line – originates at the anterior axillary fold and runs down through the anterolateral aspect of chest Midaxillary – divides lateral chest into 2 equal halves Posterior axillary – runs parallel to the midaxillary line along the posterolateral wall of the thorax 84 Anatomy of the thorax. (A) Thoracic landmarks and Imaginary lines of the chest Anatomy of the thorax. (B) Topographic landmarks of the chest and imaginary lines Thoracic Landmarks – Anterior Suprasternal notch Clavicles Sternum Angle of Louis Costal angle – Ribs – Posterior Scapulae Vertebrae – Cervical; Thoracic Ribs 87  Lung Borders Anteriorly Apex of the lung extends approx. 2-4 cm above the clavicle Normally, lungs extend down to about the level of the 6th rib Posteriorly Superior portion of lung extends to approx. the level of T-1 and down to approx. T-10 Laterally Lungs extend to the 8th rib 88  Lung Fissures Right Lung – separated into the upper, middle, and lower lobes by: Horizontal fissure – separates the right anterior upper lobe from the middle lobe Oblique fissure Anteriorly- divides the lower lobe from the lower border of the middle lobe Posteriorly – separates the upper lobe from the lower lobe Left lung – separated into the upper and lower lobes by the oblique fissure 89 Anatomy of the thorax. (A) Thoracic landmarks. (B) Topographic landmarks of the chest. (C) Surface anatomy of the thorax. 90  Examination of the Thorax and Lungs Consists of four steps: 1. Inspection (visually examining) 2. Palpation (touching) 3. Percussion (tapping) 4. Auscultation (listening with stethoscope) 91  Physical Examination Inspection  Breathing pattern Thoracic configuration Normal I:E ratio Increased with A – P Diameter Restrictive Pectus Carinatum / Decreased with Obstructive Excavatum  Breathing effort Barrel Chest (i.e., WOB emphysema) Accessory muscle use Spinal Deformities Retractions 92  Pectus Excavatum (Funnel Chest) Pectus excavatum (PE) is an abnormal development of the rib cage where the breastbone (sternum) caves in, resulting in a sunken chest wall deformity. Often present at birth (congenital) and can be mild or severe. Researchers believe that the deformity is caused by excessive growth of the connective tissue (cartilage) that joins the ribs to the breastbone (also known as the costochondral region), which causes an inward defect of the sternum. 93  Physical Examination Barrel chest—seen w/ emphysema; indicates poor lung recoil; hyperinflation When the AP diameter increases, the normal 45-degree angle of articulation between the ribs and spine is increased, becoming more horizontal. 94  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 95  Breathing Pattern and Effort (Cont.) Common causes of an increase in WOB (effort) include: Narrowed airways (e.g., COPD, asthma) “Stiff lungs” (e.g., acute respiratory distress syndrome, cardiogenic pulmonary edema, pulmonary fibrosis) Rapid, shallow breathing A stiff chest wall (e.g., ascites, anasarca, pleural effusions) One sign of severely increased work of breathing is visible distortions in chest wall, called retractions 96  Retractions An inward sinking of the chest wall during inspiration Intercostal (between the ribs) Supraclavicular (above the clavicles) Subcostal (below the rib cage) Occurs when inspiratory muscle contractions generate very large negative intrathoracic pressures Retractions can be caused by upper airway obstruction (supraclavicular), decreased lung compliance (intercostal and/or xiphoid), or inadequate gas flow to the mechanically ventilated patient. 97  Use of the Accessory Muscles of Inspiration Scalene (anterior, medial, and posterior) Sternocleidomastoid (SCD) Pectoralis major/minor Trapezius 98 Accessory Muscles of Inspiration Scalene SCD Pecs Trapezius 99 The way a patient may appear when using the pectoralis major muscles for inspiration. 100  Use of the Accessory Muscles of Expiration Rectus abdominis External oblique Internal oblique Transverse abdominis Serratus (anterior, posterior) Lattisimus dorsi 101  Rectus External Oblique Abdominis Transverse Internal Oblique Abdominis Accessory muscles of expiration 102 Accessory muscles of expiration (cont.) 103  Diaphragmatic Fatigue Found in many types of chronic and acute pulmonary diseases Signs of acute fatigue: Tachypnea Diaphragm and rib cage muscles take turns powering breathing (respiratory alternans) Abdominal paradox occurs with complete diaphragmatic fatigue Abdomen moves inward on inspiration and outward on expiration 104  Flail Chest The chest should be inspected for scars and/or trauma. Flail chest occurs when there are double fractures of multiple adjacent ribs with resulting instability of the chest wall. Leads to a paradoxical movement of the affected area (chest paradox)—in upon inspiration and out upon expiration. 105  Physical Examination Palpation - Touching the surface of the chest wall to evaluate underlying lung structure and function Thoracic Expansion - Chest/abdomen should expand synchronously during inspiration Skin – Temperature – Crepitation – Fremitus Vibration felt on palpation – Tactile fremitus – i.e., 99 – Vocal fremitus Physical Examination Estimation of thoracic expansion 107  Skin Turgor Skin turgor is the skin's elasticity It is the ability of skin to change shape and return to normal Is a sign of fluid loss (dehydration) The HCP grasps the skin between two fingers so that it is tented up. The skin is held for a few seconds then released. Normal turgor = skin “snaps” back rapidly Poor turgor = skin takes time to return to its normal position 108  Tactile and Vocal Fremitus Vocal fremitus refers to vibrations created by the vocal cords during speech Vibrations are transmitted down the tracheobronchial tree and through the lung to the chest wall When these vibrations are “felt” on the chest wall, it is referred to as Tactile fremitus Rhonchial fremitus is commonly caused by gas flowing through thick secretions that are partially obstructing the large airways. 109  Tactile and Vocal Fremitus (Cont.) Air is a poor transmitter of sound waves and vibration, therefore: Conditions that increase the ratio of air to lung tissue or increases fluid in the pleural space will DECREASE fremitus (i.e., pneumothorax, emphysema, pleural effusion, asthma) Vocal and tactile fremitus is also reduced with obese or overly muscular patients 110  Tactile and Vocal Fremitus (Cont.) Conditions that decrease the ratio of air to lung tissue will INCREASE fremitus: (i.e., consolidation) Pneumonia, Atelectasis Consolidation of the lung is simply a “solidification” of the lung tissue due to accumulation of solid and liquid material in the air spaces that would have normally been filled by gas 111  Subcutaneous Emphysema (Crepitus) Crepitus is a classic sign of barotrauma. Occurs when air escapes from the thorax and enters the subcutaneous tissue (i.e., CMV with high PAP, trauma) Air bubbles create a “crackling sound” when palpated. Frequently collects in the chest, neck, and eyes. 112  Physical Examination Percussion Tapping on the chest wall to evaluate the underlying lung fields. Avoid breast and boney structures With hand on chest tap middle finger with middle finger of other hand in short, sharp blows Compare both sides for intensity, quality, and pitch 113  Percussion (cont.) Reserved for those patients suspected of pneumothorax or lung consolidation Rapid bedside assessment of chest abnormalities Increased lung tissue or pleural space density = decreased resonance or a dull note (i.e., pneumonia, pleural effusion) Hyperinflated lungs or air in the pleural space (pneumothorax, emphysema) = increased resonance or a hyperrresonate note 114 Findings should be labeled as: normal, increased, or decreased resonance 115 -Chest percussion of a normal lung – loud, low in pitch, and long in duration (resonant/tympanic) -Similar to the sound produced when knocking on a watermelon Resonant – deep, clear, and continuing to sound or ring 116 A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation. i.e., pleural effusion, empyema, atelectasis, pneumonia, tumors 117 Percussion becomes more hyperresonant/tympanitic with alveolar hyperinflation. i.e., pneumothorax, asthma, emphysema, gastric air bubble 118 Auscultation of Lung/Breath Sounds  Auscultation of the Lungs The process of listening for bodily sounds. Performed over the thorax to identify normal and abnormal lung sounds and to evaluate the effects of therapy. Provides info relating to the status of the airways and lung parenchyma. Should be carried out in a systematic manner. 120 Bell – used to listen to heart sounds (low-pitched sounds) Diaphragm – preferred for auscultation of the lungs (high-frequency) *Always ensure the room is as quiet as possible when listening to breath sounds. 121 Auscultation of the Lungs (Technique) Patient sitting in upright position (when possible) Breathe a little more deeply than normal through an open mouth Exhalation should be passive. NOT FORCED!!! Systematically evaluate at least one FULL ventilatory cycle at each position Evaluate ALL lobes of the anterior, posterior, & lateral chest. 122  What Am I Listening For? Key Features of Breath Sounds: 1. Duration – length of inspiratory and expiratory phases (I:E) 2. Intensity – loudness 3. Pitch – vibration frequency 123 Auscultation of Lung Sounds ERRORS CORRECT TECHNIQUE Listening thru patient’s Place diaphragm directly gown/robe against the chest wall Tubing rubbing against Keep tubing away from bed rails or gown objects Auscultating in a noisy Turn television or radio room off Auscultating only in Ask patient to sit up, roll convenient areas comatose patient onto side* 124 Mechanism and Significance of Lung Sounds Normal breath sounds Lung sounds are audible vibrations primarily generated by turbulent airflow in the larger airways Sounds are altered as they travel through the lung periphery and chest wall Normal lung tissue acts as a low-pass filter It preferentially passes low-frequency sounds 125  Normal Lung/Breath Sounds TYPE LOCATION DESCRIPTION Tracheal Over trachea Loud, high pitch, hollow, harsh, inspiration equals expiration or expiration may be slightly longer than inspiration Broncho-vesicular Near main stem Softer, lower in pitch bronchi (anteriorly) than bronchial; between scapulae inspiration equals (posteriorly) expiration Vesicular Peripheral lung Soft, low-pitched, primarily heard during inspiration; exhalation is approx. 1/3 the duration of Under normal conditions, vesicular breath sounds are auscultated over most lung inhalation fields both anteriorly and posteriorly 126  Bronchial Breath Sounds Are considered abnormal when they are heard over peripheral lung fields Replace vesicular lung sounds when lung-tissue density increases When normal air-filled lung tissue becomes atelectatic or consolidated (i.e., pneumonia), the sounds auscultated are similar to tracheal breath sounds, which is considered ABNORMAL. The location at which bronchovesicular breath sounds (A) and vesicular breath sounds (B) are normally auscultated. 128  ABNORMAL/ADVENTITIOUS BREATH SOUNDS are atypical, or uncharacteristic, lung sounds that are not normally heard over a specific area of the thorax. 129  Abnormal/Adventitious Breath Sounds How to describe breath sounds: 1. Pitch: high, moderate, or low (i.e., “high-pitched wheezes were auscultated.” 2. Intensity (loudness): faint, soft, mild, moderate, or loud (i.e., “loud bronchial breath sounds were auscultated.” 3. Part of the respiratory cycle: (i.e., inspiration, expiration or both) 4. When it occurs: (i.e., late-inspiratory crackles.”) 5. Location 130  Abnormal/Adventitious Breath Sounds (cont.) Always record the precise LOCATION over the chest the abnormal breath sound is auscultated (i.e., expiratory wheezes were noted over the anterior chest, right lower lobe) Ex: High-pitched, faint, late-inspiratory wheezes were noted over the right anterior lower lobe 131  Abnormal/Adventitious Breath Sounds (cont.) Two varieties: 1. Discontinuous Intermittent, crackling, or bubbling sounds of short duration Referred to as “crackles” or “rales” 2. Continuous Referred to as “wheezes” – quasi-musical sound When heard over the upper airway is called “stridor” Heard over larynx and trachea during inspiration Common in infants and small children; sign of obstruction or edema (i.e., LTB) 132  Crackles  Occurs when airflow moves through excessive secretions or fluid in the airways.  HOWEVER, Coarse crackles (rhonchi) are CONTINUOUS Coarse crackles (rhonchi) heard during inspiration & expiration Can clear with suctioning or cough low-pitched, CONTINOUS sound that is associated with secretions in the larger airways  Fine crackles: Can be heard LATE or EARLY in the Inspiratory Phase LATE INSPIRATORY CRACKLES: Sudden opening of small peripheral airways; usually LATE in the inspiratory phase; MAY CLEAR WITH SEVERAL DEEP INSPIRATIONS or CHANGE IN POSTURE Heard with pulmonary fibrosis and atelectasis, pneumonia, pulmonary edema Faint or Low intensity crackles are often referred to as fine crackles; more pronounced or more intense crackles are referred to as coarse crackles 133  Crackles (Discontinuous) Early inspiratory crackles Larger, more proximal bronchi may close during expiration Loud or faint Not silenced by cough or a change in position Frequently occur in pt.’s with: COPD (bronchitis, emphysema, or asthma) Indicate severe airway obstruction 134  Wheezes and Stridor (cont.) Inspiratory stridor = narrowing above the glottis (supraglottic) Expiratory stridor = narrowing of the lower trachea (subglottic) In adults, stridor most often occurs from laryngeal or subglottic edema secondary to airway trauma after prolonged intubation GIVE RACEMIC EPINEPHRINE QUICK!!!! 135  Wheezes and Stridor (Continuous) Vibrations of airway wall caused when air flows at a high velocity through narrowed airways. Airway diameter can be reduced by: bronchospasm, mucosal edema, inflammation, tumors, foreign bodies, pulmonary edema Wheezing may be described as a high-pitched, whistling sound during breathing Expiratory wheezes = obstruction of intrathoracic airways (i.e., bronchitis, asthma) Monophonic – single airway partial obstruction; may be heard during either part of the respiratory cycle (inspiration or expiration) Polyphonic – multiple airways obstructed; expiration only (i.e., asthma, bronchitis, chf) 136  Whistling, Wheezing, and Chest Tightness Recurrent wheezing, chest tightness, difficulty in breathing, or a cough that may be worse at night are associated with asthma. Asthma is characterized by airway inflammation, hyperreactive airways, and reversible airway obstruction. Patients should be asked about their breathing using open-ended questions And direct questions to determine any changes in the frequency, duration, or related circumstances associated with wheezing, chest tightness, SOB, or cough 137  Whistling, Wheezing, and Chest Tightness (cont.) A change in symptoms and what factors are associated with that change should be noted. (i.e., EIA) Paroxysmal nocturnal dyspnea – acute shortness of breath at night Associated with congestive heart failure (CHF) CHF causes edema of the airways and may lead to wheezing and SOB (also known as Cardiac Asthma) 138  Abnormal/Adventitious Breath Sounds (cont’d) 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) Other causes: mucus plugs, hyperinflation of lung tissue, air/fluid in the pleural space, anasarca (extreme edema), obesity 140  Pleural Friction Rub A “creaking or grating” sound that occurs when the parietal/visceral linings become inflamed (i.e., pleurisy) Pleurisy is an inflammation of the pleurae, the membranes of the pleural cavity surrounding the lungs. May be heard during inhalation or exhalation Sounds similar to coarse crackles but is NOT cleared with coughing Intensity may increase with deep breathing 141  Abnormal Breath Sounds (Cont.) Recommended terminology for ALS are the following: Fine crackles Medium crackles, or coarse crackles Wheezes Bronchial breath sounds Stridor, pleural friction rub Diminished breath sound Whispering pectoriloquy (i.e., 1,2,3) 142  Voice Sounds Auscultation while patient vocalizes Resonance is produced during vocalization Normal lungs: Voice sounds are filtered by air-filled lung tissue which reduces intensity and clarity of words Abnormal lungs: Transmission of voice sounds is altered/enhanced 143  Voice Sounds (cont’d) Term Vocalization Clinical Diagnosis Bronchophony “99, 99, 99” increases in Increased consolidation, intensity & clarity over pneumonia the lung periphery Egophony “E-E-E” spoken becomes Heard over compressed “A-A-A” (E to A lung as in pleural egophony) effusion; consolidation Whispered Pectoriloquy “1,2,3” whispered Consolidation results in increased clarity Bronchophony or Whispered Pectoriloquy is an increased intensity and clarity of vocal resonance produced by enhanced transmission of vocal vibrations through consolidated lung tissue. 144 Adventitious Breath Sounds and Disorders 145 Adventitious Breath Sounds and Disorders (cont.) 146 General location and source of abnormal lung sounds. 147 Heart Sounds  Heart Sounds Cardiac Examination Inspection and palpation Normal/abnormal pulsations Point of maximal impulse (PMI) – a visible, palpable pulsation generated by left ventricular contraction Palm of the right hand is placed over the lower left sternal border Shifts away from a pneumothorax but towards lobar collapse Auscultation of heart sounds – patient should be  Heart Sounds (cont.) Cardiac Examination (cont.) Identifies heart sounds created by closure of heart valves S1: closure of atrioventricular valves (mitral and tricuspid) during ventricular contraction S2: closure of pulmonic and aortic valves (semilunar) – end of systole (ventricles relax) S3: abnormal – produced by rapid ventricular filling (i.e., CHF) S4: abnormal – may be a sign of heart disease Gallop rhythm – patient with heart disease who has an S3 and S4 heart sound  Cardiac Murmurs Are created by: 1. Backflow of blood through an incompetent valve (systolic) 2. Forward flow of blood through a stenotic valve (diastolic) 3. Rapid blood flow through a normal valve When caused by incompetent or stenotic heart valve are classified as diastolic or systolic. Incompetent AV Valve = Systolic murmur Obstructed flow through a stenotic Semilunar valve = Diastolic murmur 151  Abdominal Exam Patient should be placed comfortably in the supine position with table extended so patient’s legs are parallel to the ground. Typically, the abdomen is separated into (4) quadrants: R and L upper & R and L lower quadrants, utilizing the umbilicus as the landmark for differentiation of the various quadrants 152 Abdominal Quadrants  Abdominal Examination (cont.) Abdomen should be inspected and palpated for evidence of distention and tenderness. Abdominal distention and pain impair diaphragmatic movement possibly contributing to respiratory insufficiency. Abdominal dysfunction may inhibit deep breathing and coughing and promote atelectasis. 154 Components of the Abdominal Exam 1. Inspection – the 1st component of the abdominal exam; room should be well lit Abdomen observed for general shape and contour, skin color, distention, ascites, scars, pulsation, or ecchymoses (subcutaneous blood) 2. Auscultation – should be performed prior to percussion or palpation Performed using the diaphragm of the stethoscope 155 Components of the Abdominal Exam (cont.) Auscultation should be performed over all 4 anatomic locations (15 or 20 sec.) Bowel sounds should be evaluated for frequency and quality Descriptors include the following: Hyperactive bowel sounds: Loud, gurgling rushed sounds Hypoactive bowel sounds: Soft, low, widely separated sounds, (i.e., 1 or 2 occurring in 2 minutes) Absent sounds: Sounds are not heard for 3 to 5 min of auscultating in each quadrant Decreased or absent bowel sounds may be caused by a decrease or absence of peristalsis (i.e., mechanical bowel obstruction, inadequate blood supply) 156 Components of the Abdominal Exam (cont.) 3. Palpation – used to assess organ size and location of masses or abdominal pain (liver, spleen, kidneys) If masses or tenderness are noted, RT should note quadrant and begin thinking of possible causes Average patient should have a soft, nonrigid abdomen 4. Percussion – base finger pressed firmly on the patient’s bare skin while the dominant hand delivers 2 blows to the finger 157 Components of the Abdominal Exam (cont.) All 4 quadrants should be percussed, noting the quality of the note elicited Most areas of the abdomen will have a tympanic quality due to the gas located within the bowel Important finding: excessive gas, pain, pneumoperitoneum caused by abdominal trauma or perforation 158  Abdominal Examination (cont.) Intraabdominal hypertension is defined as intraabdominal pressure >12 mm Hg. Common in pt.’s with: Blunt or penetrating abdominal trauma Ruptured aortic aneurysm Bowel infarction End-stage liver failure Suspected when abdominal exam reveals pronounced distention. Hepatomegaly (enlarged liver) is a frequent cause of right lower lobe atelectasis and pleural effusion Common finding in pt.’s with liver disease and cor pulmonale 159  Abdominal Examination (cont.) Intraabdominal pressure >20 mm Hg results in Abdominal compartment syndrome Requires emergency decompressive surgery Causes profound atelectasis, hypotension, hypoxemia, and renal failure 160  Rib Fractures Painful, limit deep breathing and effective coughing, leading to atelectasis and retained secretions that increase the risk of pneumonia. When extensive, cause chest wall instability (paradoxical chest movement) that limits effective ventilation and heightens the risk for respiratory failure. Cigarette smoking and alcohol abuse further increase the susceptibility to pneumonia. 161  Rib Fractures (cont.) First priority is to increase O2 therapy to achieve adequate oxygenation while conducting examination. Worsening oxygenation, despite doubling O2 therapy, suggest refractory hypoxemia Administer high concentration O2, continuous pulse-ox, close hemodynamic monitoring Should be alert for signs of respiratory distress/increased WOB 162  Rib Fractures (cont.) Acute pulmonary embolism is another consideration. Especially if the patient also suffered any leg or pelvic fractures and was immobilized or has redness and swelling of the lower extremities. Chest should be inspected for possible pneumothorax (i.e., subcutaneous emphysema) Further workup: CXR, ABG, Blood work 163 CLINICAL LABORATORY TESTS 164  Laboratory Medicine Studies tissue and fluid specimens from patients and consists of (5) disciplines: 1. Clinical biochemistry – analyzes blood, urine, and other bodily fluids for electrolytes and proteins 2. Hematology – analyzes cellular components of blood i.e, RBC, WBC, Platelet count, Hb, HCT 3. Clinical microbiology – tests blood and other bodily fluids for infectious agents i.e., bacteria (bacteriology), viruses (virology), fungi (mycology), and parasites (parasitology) 4. Immunology – focuses on autoimmune and immunodeficiency diseases i.e., Type 1 Diabetes, Lupus, Multiple sclerosis (MS) 5. Anatomic pathology – helps diagnose diseases by analyzing tissue samples  Clinical Laboratory Tests Performed to: Evaluate general health and baseline status of the patient Identify organ system dysfunction Detect the presence of infection Determine the effects of therapy 166  Critical Test Value Result significantly outside reference range Represents pathophysiologic condition May represent potentially life-threatening situation 167  Complete Blood Count (CBC) Common test measuring formed elements of blood Counts and examines: Leukocytes (white blood cells) Made up of five different types of cells reported under the differential Erythrocytes (red blood cells) Evaluated for size and hemoglobin content Thrombocytes (platelets) – (150 – 400,000) Evaluated by the number present < 150,000 = thrombocytopenia 168  White Blood Cell Count White Blood Cell (WBC) Count Reference range: 5-10 × 103/mcL (5,000- 10,000) Leukocytosis—WBC count above normal Common with infection, stress, and trauma. Degree of leukocytosis depends on severity of infection Severe infection with mild leukocytosis may represent poor prognosis 169  White Blood Cell Count (Cont.) Leukopenia—WBC below normal Occurs with overwhelming infections and when immune system is depressed due to disease or certain cancer therapies (chemotherapy) Diseases of bone marrow (e.g., leukemia) Neutrophilia—Elevation of the absolute value of neutrophils (sign of severe infection) Neutropenia – a reduced number of circulating neutrophils (i.e. Lymphoma, leukemia, autoimmune disorders, HIV, chemo) 170  Differential of WBC Count Determines the number of each type of WBC present in the blood Most circulating WBCs are either neutrophils or lymphocytes White blood cells come in five varieties 1. Neutrophils* - 1.8-6.8 X 109/L 2. Lymphocytes* - 1.0-3.4 x 109/L 3. Eosinophils – 0-0.4 x 106/L 4. Basophils – 0-0.1 x 106/L 5. Monocytes – 0.2-0.8 x 106/L Elevation of the WBC count usually is caused by an increase in either neutrophils or lymphocytes in response to infection. 171  Red Blood Cell Count Red blood cell (RBC) count Reference range: Men : 5 million/mm 3 Women: 4.5 million/mm3 Reduced RBC is called anemia < 4 million/mm3 Due to either blood loss or reduced RBC production by bone marrow Anemia reduces oxygen-carrying capacity of blood Several types of anemia exist with different causes (dietary deficiencies, chronic inflammatory disease, hereditary) Severe anemia is treated with transfusion (Hb < 7) 172  Red Blood Cell Count (Cont.) Polycythemia—Abnormal elevation of RBC, Hb, or HCT count Hb of > 18 gm/dl HCT of > 55% Secondary polycythemia occurs when bone marrow is stimulated to produce more RBCs in response to chronically low blood oxygen levels Common in people who live at an elevated altitude and in patients with chronic hypoxemic lung disease 173  Red Blood Cell Count (Cont.) RBC count includes hemoglobin and hematocrit levels Hemoglobin (Hb) Plays role of bonding with oxygen Reference range: Men 13.3-17.7 g/dl Women 11.7-15.7 g/dl The recommended threshold for blood transfusion is a hemoglobin < 7.0 g/dL or hematocrit of 21% 174  Red Blood Cell Count (Cont.) Hematocrit Levels Ratio of RBC volume to that of whole blood Proportion of sample represented by packed cells Reference range : Men 40%-52% Women 35%-47% Low levels occur with anemia or overhydration High levels occur with polycythemia and dehydration 175  Electrolyte Test Basic Concepts Normal cellular function depends upon homeostasis of fluid, electrolytes, and acid- base balance Electrolytes are ions that influence functioning of enzymes Enzymes are proteins regulating all chemical reactions occurring within cells (metabolism, protein synthesis) 176  Basic Chemistry Panel Also called a basic metabolic panel (BMP) Predominant electrolytes measured in lab: Sodium (Na+) – 135-145 mEq/L Potassium (K+) – 3.5-5.0 mEq/L Chloride (Cl−) – 98-106 mEq/L Glucose (GL) – 70-110 mg/dl Excretion of renal-mediated waste products is included in panel: Creatinine (Cr) = 0.5-1.5 mg/dL Blood urea nitrogen (BUN) = 6-20 mg/dL 177  Cardiac Enzymes CPK (22-198 U/L) Creatine phosphokinase (CPK) or creatinine kinase, is found mainly in heart, brain, and skeletal muscle tissue. Levels will be elevated during sustained ischemic damage to the tissues (i.e., heart, brain, skeletal muscle) CPK-2 (MB) is the most common CPK test and is released from the heart after Myocardial infarction Levels increase 4-6 hrs. and peak 12-24 hrs. after injury. Monitored in pt.’s with suspected MI, cardiac contusion, open heart surgery, or myocarditis 178  Cardiac Enzymes (cont’d) Troponin Complex protein that helps regulate skeletal and cardiac muscle contractility. More commonly used than CPK-2 Troponin I Levels will peak 12-16 hrs. after MI. (>0.05 ng/L) B-Type Natriuretic Peptide (BNP) is used to evaluate patients for heart failure ( 300 = mild HF; >600 = moderate HF; >900 = severe HF 179  Enzyme Tests (Cont.) Coagulation Studies The process by which the blood forms clots to stop bleeding and repair blood vessels Thrombocytopenia (low platelets 400,000) Causes excessive clotting 180  Enzyme Tests (Cont.) Coagulation studies used to measure function Prothrombin Time (PT) – seconds it takes plasma to form a clot Partial Thromboplastin Time (PTT) – used to evaluate abnormalities in blood clotting and monitor the effects of anticoagulation tx PT is accompanied by an additional measurement— International Standardized Ratio (INR) 0.9-1.3…values of 5 indicate high likelihood of bleeding…values of 0.5 associated with increased clotting These tests assess 2 different pathways by which fibrin clots are formed 181 Enzyme Tests (Cont.) 182  Enzyme Tests (Cont.) Sweat Chloride Cystic Fibrosis (CF) CF patient’s have elevated level of sweat Cl− 40-60 mmol/L is borderline < 40 mmol/L are unlikely to be diagnosed Must be accompanied by other tests to confirm diagnosis 183  Microbiology Sputum Gram Stain Suspected infection in lungs or airways may benefit from analysis of sputum sample The first test used in evaluating sputum samples Gram stain can determine if offending organism is gram positive or gram negative and its shape Legitimate sputum sample will have numerous pus cells (leukocytes) and few epithelial cells (If saliva is expectorated, sample is invalid) Although a gram stain can be helpful in identifying an invading organism so antibiotics can be quickly started, a definitive diagnosis is made only by culture of the specific organism over several days 184  Microbiology (cont.) Sputum Culture (C &S) If the gram stain reveals an adequate sample, the lab technician prepares a portion of the sputum for culture. Sample is placed in a medium permitting growth of the organism When the organism has matured, it is examined microscopically to determine its exact type and sensitivity to antibiotic therapy 185  Sputum Culture for AFB/PCP Acid-fast testing for AFB Identifies acid-fast bacterium Mycobacterium tuberculosis causes pulmonary tuberculosis Pneumocystis pneumonia (PCP) is a serious infection caused by the fungus Pneumocystis jirovecii. Most people who get PCP have a medical condition that weakens their immune system or take medicines that lower the body’s ability to fight germs and sickness (i.e., HIV/AIDS*) Symptoms include: fever, cough, difficulty breathing, chest pain, chills, fatigue