5 Patient Assessment Skills You Need To Know To Crush The TMC-RRT Exam!
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Physical exam involves observing, palpating, percussing, and auscultating the patient. All of these methods reveal clues to the source of the patient’s problems. Physical exam clues are included in a large majority of questions on the board exams. Knowing physical exam terminology and how it relates to your patient will serve you well on the TMC-RRT exam.
Palpation involves putting your hands on the patient to measure chest expansion, palpate for tactile fremitus, and assess for tracheal deviation.
A. Chest expansion
Evaluate chest expansion by placing both hands on the patient’s chest and measuring the distance each hand moves apart during inhalation. Symmetrical chest expansion on both sides is normal.
Asymmetrical chest movement is abnormal. Common causes include:
2. Right mainstem intubation
4. Flail chest is caused by severe chest wall trauma such as multiple broken ribs. Flail chest causes paradoxical motion of the affected side as compared to the normal side of the chest.
5. Seesaw movement of the abdomen and chest occurs when the diaphragm fatigues such as often occurs with paralyzed patient’s. This should not be confused with flail chest.
Decreased chest expansion may be due to neuromuscular diseases or the result of an already hyperinflated chest due to COPD.
B. Tactile Fremitus
Fremitus is another word for vibrations. Vibrations from the patient’s speech are known as vocal fremitus. When the clinician feels the vibrations with their hands while the patient speaks, the vibrations become known as tactile fremitus. The clinician describes the vibrations as increased, decreased, or absent. Vibrations are transmitted better through consolidated lungs than clear lungs.
Increased fremitus is associated with:
2. Lung tumors
Decreased fremitus is associated with:
3. Pleural effusion
4. Obese or very muscular patients
Rhoncial fremitus is associated with secretions and can usually be cleared with a cough.
C. Tracheal Deviation
Understanding which direction the trachea shifts in patients with pneumonia, pleural effusion, pneumothorax, or atelectasis will greatly increase your chances of passing the board exams. Fortunately, there are two simple things to remember that will help you determine what is causing the trachea to shift.
1. Lung problems outside the lung, such as pleural effusions or pneumothorax, push the trachea away
2. Lung problems inside the lung, such as pneumonia or atelectasis, pull the trachea towards them.
Diagnostic Chest Percussion
Percussing the chest wall produces distinct sounds that help evaluate the underlying tissue.
1. First, place only the middle finger firmly against the chest and between the ribs. Strike the first joint of the middle finger with your opposite middle finger tip.
2. Next, evaluate the intensity (loudness) and pitch while comparing both sides of the chest.
Normal chest percussion produces an easily heard low-pitched sound when percussed. This is known as resonant.
Abnormal chest percussion
Dull or decreased resonance occurs when the density in or around the lung increases. Common causes include:
1. Pleural effusion
Hyperresonant lungs produce a loud, hollow sound when percussed. This occurs as a result of excessive air trapped in the lung or pleural space. Common causes include:
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Auscultation Of The Lungs
Normal breath sounds
Vesicular and bronchial breath sounds are considered normal when they are heard in the correct place.
1. Vesicular breath sounds are quiet, low pitched, soft intensity sounds heard over the peripheral (outer) lung regions.
2. Bronchial breath sounds are harsh, loud sounds. Bronchial breath sounds are heard over the large airways such as the bronchial tubes and trachea. Bronchial breath sounds heard over the lung bases would suggest a consolidation such as pneumonia.
Abnormal Breath Sounds
Breath sounds such as bronchial breaths sounds heard over the lung periphery and diminished breath sounds are considered abnormal. Technically, these breath sounds are not considered adventitious because they are not added sounds superimposed on top of normal sounds.
1. Abnormal bronchial breath sounds replace vesicular sounds when that part of the lung increases in density. Pneumonia may cause bronchial breath sounds where vesicular breath sounds should be heard. If a test question stated bronchial breath sounds are heard in the lung bases or periphery, you would suspect a consolidation such as pneumonia.
2. Diminished breath sounds may sometimes be referred to as distant on the NBRC exam. Anything that causes a reduction of airflow or blocks the transmission of sound through the lung may cause diminished breath sounds.
Causes of diminished breath sounds may include:
a. Pneumothorax causes air to accumulate in the pleural space and reduces air movement in the collapsed lung. Diminished or distant breath sounds may indicate pneumothorax. However, absent breath sounds are considered a hallmark sign of pneumothorax.
b. Pleural effusions cause fluid to accumulate in the pleural space. This creates a physical barrier to transmission of breath sounds.
c. COPD patients have diminished breath sounds due to air trapping and hyperinflated lungs.
d. Foreign body airway obstruction and mucous plugging may also reduce airflow causing diminished breath sounds over the obstructed lung.
e. Obese patients may have diminished breath sounds due to poor sound transmission.
f. Overly sedated patients may have diminished breath sounds due to shallow or slow breathing.
Adventitious breath sounds
Adventitious breath sounds are abnormal added or extra sounds superimposed over normal breath sounds during auscultation of the lungs.
1. Wheeze is a continuous high-pitched sound.
2. Asthma – If due to asthma wheezing should be bilateral. There is no such thing as unilateral asthma. Recommend aerosolized albuterol if wheezing is bilateral and asthma is suspected. If breath sounds change from wheezing to markedly diminished after receiving aerosolized albuterol, the patient is getting worse and needs more aggressive therapy. Recommend a continuous nebulizer with a higher dose of albuterol.
3. Foreign body airway obstruction – Unilateral wheezing is highly suspicious for foreign body airway obstruction, particularly in a child. Unilateral wheezing caused by foreign body aspiration can be treated with rigid bronchoscopy. Of course, if the patient shows signs of hypoxemia you must remember your priorities and give oxygen first.
4. Fine crackles are most often due to pulmonary edema and atelectasis. Fine crackles cannot be cleared with suctioning. For patients with fine crackles due to CHF/pulmonary edema recommend: oxygen, diuretics such as Furosemide or Lasix, and positive inotropic agents.
5. Coarse crackles occur when secretions move in the airways due to pneumonia or bronchitis. Coarse crackles due to secretions are heard on both inhalation and exhalation. Recommend coughing and/or suctioning for patients with coarse crackles.
6. Stridor is a serious sign of airway obstruction. This can be due to foreign body airway obstruction, post extubation edema, or croup. Stridor is audible mostly during inspiration. Treatment of stridor depends on its severity:
a. Mild/moderate stridor – If stridor is only moderate and the patient is stable, you will have time to treat it without intubation. Recommend oxygen, racemic epinephrine, rigid bronchoscopy if foreign body airway obstruction.
b. Severe stridor – Severe stridor often occurs in patients with epiglottitis. Severe stridor compromises both ventilation and oxygenation of the patient. Severe stridor requires immediate intervention. Therefore, recommend intubation for a patient with severe stridor.
Auscultation Of The Voice
Auscultation of voice sounds helps detect lung consolidations such as pneumonia. Voice sounds change as they move over consolidated lungs. Any change in voice sound or intensity while auscultating may indicate pneumonia.
1. Egophony – while auscultating each lung field, the patient is instructed to say the letter “E”. In normal lungs, without any disease process, the E will sound like an E. However, when there is a consolidation, such as with pneumonia, the “E” will sound like an “A”.
2. Bronchophony – while auscultating each lung field, the patient is instructed to recite the word “ninety-nine”. If an increased intensity and clarity is noted, the patient may have a consolidation such as pneumonia.
3. Whispered pectoriloquy – while auscultating each lung field the patient is instructed to whisper “ninety-nine”. If these words are clear it is suggestive of a consolidation such as pneumonia.
Normal configuration– The chest diameter from front to back should be less than the side-to-side diameter. In more technical terms, the Anterior-posterior diameter should be less than the transverse diameter.
Abnormal thoracic configurations:
1. Atrophy – both neuromuscular disease and prolonged mechanical ventilation can cause wasting away of the accessory muscles. These patients often have trouble clearing airway secretions. The therapist can recommend the patient use an in-exsufflation device to assist the patient with airway secretion clearance.
2. Hypertrophy – patients with severe COPD rely on these muscles to breathe even while at rest. This is due to the loss of elastic recoil in their lungs and displacement of the diaphragm due to air trapping. As a result, the accessory muscles of respiration become enlarged.
3. Barrel chest – Patients with severe COPD may have increased A-P diameter due to hypertrophy of accessory muscles and hyperinflation (air trapping). Think of the terminology barrel chest, air trapping, increased A-P diameter, and hyperinflation as all being synonymous with each other and also associated with COPD.
Work of breathing
Normal Work of Breathing
Patients with a normal work of breathing will have a normal respiratory rate and rhythm. The abdomen will move gently outward with inhalation and inward with exhalation. The accessory muscles of respiration will be only slightly active.
Labored or Increased Work of Breathing
Signs may include increased accessory muscle use, retractions, tracheal tugging, nasal flaring, or the patient’s subjective complaint of shortness of breath and/or dyspnea.
1. Accessory muscle use is associated with increased airway resistance and muscle fatigue. Accessory muscles include the scalene, sternocleidomastoid, pectoralis major, trapezius, and internal intercostal.
2. Retractions appear as an inward depression of the skin around the chest wall caused by forceful inspiration. Retractions can be intercostal, supraclavicular, and sternal. Retractions are a sign of severe airway obstruction and/or respiratory distress.
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