1Assessments in Respiratory Care

Wilkins 7th edition, Chapter 5

Fundamentals of Physical Examination
Assignment Due: Friday January 22, 2016
Submit to FOL RESP3012 DropBox before midnight
1.

Describe the four components of the physical examination.

The four basic components of the physical examination are inspection, palpation, percussion,
and auscultation.
Inspection visual examination for detection of features or qualities perceptible to the eye.
Palpation is the process of using one's hands to examine the body, especially while
perceiving/diagnosing a disease or illness.
Percussion striking a part of the body with short, sharp blows of the fingers inorder to deter
mine the size, position, and density of the underlying parts by the sound obtained.
Auscultation listening for sounds produced within the body, chiefly to assess the condition
of the thoracic orabdominal organs and vessels such as the heart, lungs, aorta, and intestines.

2.

Explain the importance of reviewing the history of present illness before performing a
physical examination.
This review gives the patient care team insight into the expected physical examination
findings and suggests the techniques to emphasize.

3.

Identify the correct method for measuring jugular venous pressure and expected normal
findings.
In the supine position, the neck veins of a healthy person are full. When the head of the bed
is elevated gradually to a 45-degree angle from horizontal, the level of the column of blood
descends to a point no more than a few centimeters above the clavicle with normal venous
pressure. With elevated venous pressure, the neck veins may be distended as high as the
angle of the jaw, even when the patient is sitting upright. The degree of venous distention
can be estimated by measuring the distance the veins are distended above the sternal angle.
The sternal angle has been chosen universally because its distance above the right atrium
remains nearly constant (approximately 5cm) in all positions. With the head of the bed
elevated to a 45-degree angle, venous distention greater than 3 to 4 cm above the sternal
angle is abnormal.

4.

Describe the significance of the following during examination of the head and neck:
Nasal flaring: Nasal flaring is identified by observing the external nares flare outward during
inhalation. This may occur in patients of any age but is most often seen in neonates and
young children with respiratory distress. It suggests that an increase in the work of breathing
is present. It may be seen in a large variety of clinical conditions, including upper airway
obstruction, bronchiolitis, pneumonia, and respiratory distress syndrome.
Cyanosis: Cyanosis may be detected, especially around the lips and oral mucosa, when

respiratory disease results in reduced oxygenation of the arterial blood. Cyanosis is a bluish
cast to the skin that clinically may be difficult to detect, especially in those with moderate to
severe anemia. The presence of cyanosis is strong evidence that tissue oxygenation may be
less than optimum; further investigation (e.g., arterial blood gas analysis) is indicated. The
absence of cyanosis does not indicate that tissue oxygenation is adequate because a
sufficient hemoglobin concentration must exist before cyanosis can be identified.
Pursed-lip breathing: Pursed lip breathing (PLB) is the breathing technique that
consists of exhaling
Through tightly pressed (pursed lips) and inhaling through nose with mouth closed. The
purpose for this
Technique is to create a back pressure in the airway and lungs. Breathing through the
nose and out through
The mouth is a slow and controlled manner. This creates a back pressure in the airway to
keep them open With passive, relaxed expiration with gently pursed lips. COPD patients get
some relief with this technique.
Diaphoresis: Excessive sweating by the patient. It usually occurs at many sites in the
body at the same time but is often first appreciated during inspection of the patients face. It
is a common finding in patients in acute respiratory distress and in those having severe pain.
It also may be seen with exercise, eating spicy foods, fever, menopause, and other scenarios.
Diaphoresis is also common in patients experiencing a myocardial infarction. For this reason,
diaphoresis should always be taken seriously especially in the patient at risk for heart
disease.
Changes in pupillary size in response to light: Pupillary light reflexes provide
information regarding
status of the brain and the sympathetic and parasympathetic
nervous system. Pupillary function is controlled by
the midbrain and evaluates CNs 2 and 3. Pupillary reflex is determined by passing bright light
in front of both opened eyes while carefully watching the iris in both eyes of movement. Pupil
size,
congruency, and respond to light and accommodation should be described.
Shift of the trachea : Upon physical examination, a tracheal deviation may be
detected. This means that the trachea (windpipe) has shifted more towards one side, either
left or right. Any midline shift of the trachea should be investigated further for the cause,
however, it should be noted other signs and symptoms will also be evident. Tracheal deviation
does not only indicate pathology of the trachea itself. Any shift of the mediastinum,
particularly the upper mediastinum, will result in a tracheal deviation. The mediastinum is the
compartment in the center of the chest cavity, which also houses the heart and major blood
vessels, and is surrounded on the left and right by the pleural cavity containing the lungs.
Tracheal shift towards lung problem consist of Atelectasis, Pleural fibrosis, Pneumonectomy,
Lung agenesis Tracheal shift away from the lung consist of Pneumothorax, Pleural effusion,
and Tumours.
Jugular venous distention: The level of jugular venous distention may vary with breathing.
During inhalation, the level of the column of blood may descend toward the thorax and return
to the previous position with exhalation. For this reason, JVP should always be estimated at
the end of exhalation. The most common cause of jugular venous distention is right-sided
hear failure. Right-sided heart failure may occur secondary to left-sided heart failure or
chronic hypoxemia. Hypoxemia initiates pulmonary vasoconstriction and increases the
resistance to blood flow through the pulmonary vasculature, increasing the workload of the
right ventricle. Persistent lung disease with hypoxemia may result in right-sided heart failure
and jugular venous distention. Jugular venous distention also may occur with hypervolemia
and when the venous return to the right atrium is obstructed by tumors in the mediastinum.

___Mohamad Rahman______________________
Name
Signature
5.

______22 January 2016

Date

Refer to your anatomy textbook and identify the bones of the thorax:

First rib

Costal cartilage

True rib

False rib

False rib

Floating rib

Floating rib

Thoracic 12 vertebra

Xiphoid

Body of sternum (gladiolus)

Manubrium of sternum

Sternoclavicular joint

Jugular notch

6.

Define the following terms used to classify thoracic configuration:

Pectus carinatum: Outward stenal protrusion anteriorly.

Pectus excavatum: Depression of part or all of the sternum

Kyphosis: Spinal deformity in which the spine has an abnormal anteroposterior

curvature.

Scoliosis: Spinal deformity in which the spine has a lateral curvature.

Kyphoscoliosis: Combination of kyphosis and scoliosis.

Barrel chest: The abnormal increase in anteroposterior diameter.

Flail chest: A section of the rib cage may move paradoxically with breathing
when multiple ribs are fractured at more than one site. The paradoxical motion is
seen as a sinking inward of the affected region with each spontaneous inspiratory
effort and an outward movement with subsequent exhalation. This paradoxical motion
of the affected rib cage is called flail chest.

Costal Angle: The costal angle is the angle beneath the the sternum. It is
created by the costal cartilage that joins what are called the false ribs, the ones that
do not directly attach to the sternum via their own cartilage, but attach directly and
indirectly to the cartilage of the 7th rib. This angle is created because these false ribs
get shorter as they go down. Since they are connected by the descending costal
cartilage which travels laterally and inferiorly from the sternum, it creates the angle
known as the costal angle.

7.

Where does the trachea bifurcate anteriorly and posteriorly?

On the anterior chest, the carina (tracheal bifurcation) is located approximately
beneath the sternal angle (angle of Louis) and on the posterior chest at approximately
T4.

8.

Define the following breathing patterns. List the cause and characteristics.

Apnea:
Characteristic: No breathing
Cause: Cardiac arrest
Biots breathing
Characteristic: Irregular breathing with long periods of apnea
Cause: Increased intracranial pressure
Cheyne-Stokes breathing
Characteristic: Irregular type of breathing; breaths increase and decrease in
depth and rate with periods of apnea
Cause: Diseases of central nervous system, congestive heart failure.
Kussmauls breathing
Characteristic: Deep and fast
Cause: Metabolic acidsis
Apneustic
Characteristic: Prolonged inhalation
Cause: Brain damage

Paradoxical breathing
Characteristic: Injured portion of chest wall area moves in the opposite
direction to the rest of the chest
Cause: Chest trauma

9.

Describe the breathing patterns associated with restrictive and obstructive lung
disease.
Restrictive: Patients with restrictive lung disease (reduced lung volumes) typically
breathe with a rapid (tachypnea) and shallow (hypopnea) pattern.
Obstructive: Acute obstruction of intrathoracic airways, as occurs with asthma, results
in a prolonged exhalation time. With more severe cases of airway obstruction, the I:E
ratio may be 1:3, 1:4, or even longer at 1:5 or greater. Acute upper airway
obstruction, as occurs with croup or epiglottitis, often results in a prolonged
inspiratory time.

10.

Describe the clinical significance of accessory muscle uses and retractions and
bulging.
The sternocleidomastoid and the scalene muscles are typically considered accessory
muscles of breathing. Both assist in elevating the rib cage. The involvement of these
muscles seems to depend on the degree of respiratory effort. During quiet breathing,
the scalene are consistently physically active, while the sternocleidomastoids are
quiet. With an increase in the respiratory volume, sternocleidomastoids also become
active. Both muscles are simultaneously activated when one breathes in at the maximal
flow rate.

11.

Describe the clinical significance of peripheral vs. central cyanosis.

Peripheral cyanosis is the blue tint in fingers or extremities, due to inadequate
circulation. The blood reaching the extremities is not oxygen rich and when viewed
through the skin a combination of factors can lead to the appearance of a blue color.
Peripheral cyanosis can be observed in the absence of heart or lung failures.
Central cyanosis is often due to a circulatory or ventilatory problem that leads to poor
blood oxygenetion in the lungs. It develops when arterial oxygen saturation drops to
85% or 75%. Acute cyanosis can be a result of asphyxiation or choking, and is one
of the surest signs that respiration is being blocked.

12.

Identify a definition for the following terms and their significance:


Abdominal paradox: As the accessory muscles contract in an effort to
cause gas abdominal paradox, which is an important finding that occurs with
paralysis or fatigue of the diaphragm.

Respiratory alternans: Abdominal paradox may be accompanied by

respiratory alternans. Respiratory alternans consists of periods of breathing
using only the chest wall muscles alternating with periods of breathing entirely
by the diaphragm.
Peripheral cyanosis The presence of cyanosis in the digits (peripheral
cyanosis or acrocyanosis) indicates that the blood flow contains a reduction
in oxygen-saturated hemoglobin. The patient with peripheral cyanosis resulting
from poor perfusion also has extremities that are cool to the touch because
vasoconstriction may occur due to cold ambient temperature.
Central cyanosis the bluish discoloration of the capillary beds observed
most easily around the lips and oral mucosa.

Hoovers sign

COPD patients with severe hyperinflation have a low, flat diaphragm with
limited mobility. Contraction of the flattened diaphragm pulls the lateral
margins of the chest wall inward during each inspiratory effort. This abnormal
movement of the lateral chest wall during breathing in COPD patients with
severe hyperinflation is known as Hoovers sign.
13.

Define the following terms and their significance during examination of the
extremities:

Digital clubbing
Clubbing of the digits is a significant manifestation of cardiopulmonary disease.
The mechanism responsible for clubbing is not known, but it is often
associated with a chronic cardiopulmonary disease. It is identified most
commonly in patients with cyanotic congenital heart disease, bronchogenic
carcinoma, COPD, cystic fibrosis, and bronchiectasis. Clubbing is characterized
by a painless bulbous enlargement of the terminal phalanges of the fingers and
toes, developing over many years.
Cyanosis:
Examination of the fingertips and toes indicates the presence or absence of
cyanosis, a blue, gray, or purplish appearance of the skin, common in patients
with severe cardiopulmonary disease. The ability to observe cyanosis depends
on the patients skin pigmentation and lighting in the room and may be
masked by severe anemia. The presence of cyanosis in the digits (peripheral
cyanosis or acrocyanosis) indicates that the blood flow contains a reduction in
oxygen-saturated hemoglobin. The patient with peripheral cyanosis resulting
from poor perfusion also has extremities that are cool to the touch because
vasoconstriction may occur due to cold ambient temperature. Tissue
oxygenation may be compromised in such situation.

Pedal edema
When the venous return to the right side of the heart is reduced, the peripheral
blood vessels engorge, resulting in an accumulation of fluid in the
subcutaneous tissues of the ankles, called pedal edema. The ankles most often
are affected because they naturally are maintained in a gravity-dependent
position throughout the day. The edematous tissues pit (indent) when pressed
firmly with the fingertips. The severity of edema usually is characterized by
the examining physician using a scale of 1+ to 4+, with 1+ indicating slight
edema and 4+ indicating severe edema.

Capillary refill:
Capillary refill is assessed by pressing firmly for a brief period on the fingernail
and identifying the speed at which the blood flow returns. When cardiac output
is reduced the blood flow returns. When cardiac output is reduced the blood
flow returns. When cardiac output is reduced and digital perfusion is poor,
capillary refill is slow, taking several seconds to appear. In normal persons with
good cardiac output and digital perfusion, capillary refill should take less than 3
seconds.

Peripheral skin temperature

When the heart does not circulate the blood at a sufficient rate, compensatory
vasoconstriction occurs in the extremities to shunt blood toward the vital
organs.
The reduction in peripheral perfusion results in a loss of warmth in the
extremities.
Palpation of the patients feet and hands may provide general information
about perfusion. Cool extremities usually indicate inadequate perfusion.
The extremity should be at least 2 C warmer than room temperature When
there is less than 2 C difference, perfusion is reduced; a 0.5 C difference
indicates that the patient has serious perfusion problem

14.

How does pursed-lip breathing help the patient with COPD?

15.

Slows your breathing down.

Keeps airways open longer so your lungs can get rid of more stale, trapped air.
Reduces the work of breathing.
Increases the amount of time you can exercise or perform an activity.
Improves the exchange of oxygen and carbon dioxide.

Discuss the following terms related to assessing the pupils:

 PERRLA: If the pupils are equal in size, round, and reactive to light and
accommodation, the physician may simply write PERRLA.

Miosis: Parasympathetic stimulants and opiates can cause pinpoint pupils.

Mydriasis: Brain death, catecholamines, and atropine can cause the pupils to
become dilated and fixed.
Ptosis: Drooping of the upper lid (ptosis) may be an early sign of disease
involving the third cranial nerve.
Diplopia: Neuromuscular diseases affecting the cranial nerves also may result
in blurred or double vision.
16.

Reproduce the Glasgow Coma Scale on the next page ... Table 6-2, page 111 in your
Wilkins textbook.