RET 1024
Introduction to Respiratory Therapy
Module 4.2
Bedside Assessment of the Patient
― Inspection
Bedside Assessment of the Patient
Systematic Examination Thorax and Lungs
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The physical examination of the chest and lungs should be
performed in a systematic and orderly fashion – the most
common sequence is as follows:
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Inspection
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Palpation

Percussion

Auscultation
Bedside Assessment of the Patient
Systematic Examination Thorax and Lungs

Topographic landmarks of the lung and chest
Bedside Assessment of the Patient
Systematic Examination Thorax and Lungs
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Topographic landmarks of the lung and chest
Bedside Assessment of the Patient
Systematic Examination Thorax and Lungs
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Topographic landmarks of the lung and chest
Bedside Assessment of the Patient
Systematic Examination Thorax and Lungs
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Topographic landmarks of the lung and chest
Bedside Assessment of the Patient
Systematic Examination Thorax and Lungs
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Topographic landmarks of the lung and chest
Bedside Assessment of the Patient
Systematic Examination Thorax and Lungs

Topographic landmarks of the lung and chest
Left oblique fissure
Left upper lobe
Left lower lobe
Bedside Assessment of the Patient
Systematic Examination Thorax and Lungs
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Topographic landmarks of the lung and chest
Bedside Assessment of the Patient
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Inspection
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Dyspnea
Abnormal ventilatory pattern
Use of accessory muscles of inspiration
Pursed-lip breathing
Substernal or intercostal retractions
Nasal flaring
Splinting due to chest pain
Bedside Assessment of the Patient
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Inspection
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Abnormal extremity findings:
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Altered skin color
Digital clubbing
Pedal edema
Capillary refill
Distended neck veins
Tracheal deviation
Cough (note characteristics)
Sputum production
Hemoptysis
Bedside Assessment of the Patient
 Dyspnea; shortness of breath as defined
by the patient
 Patient’s sense that their work of breathing is
excessive for their level of activity
 Shortness of breath becomes a concern when
the drive to breathe is excessive or when the
work of breathing increases
Bedside Assessment of the Patient
 Dyspnea
 Drive to breathe is excessive
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Hypoxemia
Acidosis
Fever
Exercise
Anxiety
Bedside Assessment of the Patient
 Dyspnea
 Increased work of breathing
 Narrowed airways, e.g.,
 Asthma
 Bronchitis
 Lung become difficult to expand, e.g.,
 Pneumonia
 Pulmonary edema
 Chest wall abnormality
Bedside Assessment of the Patient
 Dyspnea
 Positional
 Reclining – Orthopnea
 CHF
 Bilateral diaphragmatic paralysis
 Upright - Platypnea
Bedside Assessment of the Patient
 Dyspnea
 Patient’s description of their dyspnea
“My chest is tight”
“My breathing is too fast”
“I feel like I’m suffocating”
Bedside Assessment of the Patient
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Inspection
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Abnormal Ventilatory Pattern
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Provide reliable clues about underlying pulmonary
problem
Rapid shallow breathing (Rate with a VT )
 Caused by  lung volume and/or  lung compliance (CL)
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Atelectasis
Pneumonia
Pulmonary edema
Pleural effusion
Pneumothorax
Adult respiratory distress syndrome (ARDS)
Bedside Assessment of the Patient
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Inspection
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Abnormal Ventilatory Pattern
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Prolonged exhalation time ( Rate with a  VT )
 Caused by  airway resistance (Raw)
 Cystic fibrosis
 Brochiectasis
 Asthma
 Bronchitis
 Emphysema
Bedside Assessment of the Patient
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Inspection
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Abnormal Ventilatory Pattern
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Prolonged inspiratory time
 Upper airway obstruction – extrathoracic
 Epiglotitis
 Croup
 Extrathoracic tumor
Bedside Assessment of the Patient
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Inspection
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Use of accessory muscles
 During the advanced stages of chronic obstructive
pulmonary disease (COPD), the accessory muscles of
inspiration are activated when the diaphragm becomes
significantly depressed by the increased residual
volume (RV) and functional residual capacity (FRC)
 Accessory muscles of inspiration
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Scalene
Sternocleidomastoid
Pectoralis major
Trapezius
Bedside Assessment of the Patient
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Inspection
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Use of accessory muscles
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Accessory muscles of expiration
 Recruited when airway resistance becomes
significantly elevated
 Rectus abdominis
 External obliques
 Internal obliques
 Transversus abdominis
Bedside Assessment of the Patient
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Inspection
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Use of accessory muscles
Bedside Assessment of the Patient
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Inspection
 Pursed-lip Breathing
 Occurs in patients during the
advanced stages of obstructive
pulmonary disease
 Patient exhales through lips that
are held in position similar to that
used for whistling or blowing trough
a flute
 Retarding the airflow through the
pursed lips provides the airway with
some stability - offsets early airway
collapse
Bedside Assessment of the Patient
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Inspection
 Pursed-lip Breathing
Bedside Assessment of the Patient
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Inspection
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Retractions
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Caused by a greater than normal negative intrapleural
pressure during inspiratory efforts to overcome low
lung compliance as seen in patients with severe
restrictive lung disorders, e.g., pneumonia, ARDS, and
in premature newborns with surfactant deficiencies or
idiopathic respiratory distress (IRDS)
 Sternal
 Intercostal
 Supraclavicular
 Subcostal
Bedside Assessment of the Patient
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Inspection
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Retractions
Supraclavicular retractions
Sternal retractions
Intercostal retractions
Subcostal retractions
Bedside Assessment of the Patient
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Inspection
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Nasal Flaring
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Often seen during
inspiration in infants
experiencing
respiratory distress
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Provides a larger
orifice for gas to
enter the lungs
during inspiration
Bedside Assessment of the Patient
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Inspection
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Splinting Due to Chest Pain
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Pleuritic Chest Pain
 Sudden sharp, stabbing type pain located laterally
or posteriorly
 Worsens with deep breath
 Origin may be from:
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Chest wall
Muscles
Ribs
Diaphragm
Mediastinal structures
Intercostal nerves
Parietal pleura (pleurisy)
Bedside Assessment of the Patient

Inspection
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Splinting Due to Chest Pain
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Pleuritic Chest Pain
 A characteristic feature of the following respiratory
diseases:
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Pneumonia
Pleural effusion
Pneumothorax
Pulmonary infarction
Lung cancer
Pneumoconiosis
Fungal diseases
TB
Bedside Assessment of the Patient

Inspection
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Splinting Due to Chest Pain
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Nonpleuritic Chest Pain
 Described as constant “dull ache” or “pressure”
located in the center of the anterior chest, may
radiate to the shoulder
 Associated with the following disorders:
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Myocardial ischemia
Pericardial inflammation
Pulmonary hypertension
Esophagitis
Local trauma or inflammation of the chest cage,
muscles, bones, or cartilage
Bedside Assessment of the Patient
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Inspection
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Abnormal Chest Configuration
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During inspection the respiratory care practitioner
systematically observes the patient’s chest for both
normal and abnormal findings
 Is the spine straight?
 Are any lesions or surgical scars evident?
 Are the scapulae symmetric?
Bedside Assessment of the Patient
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Inspection
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Abnormal Chest Configuration
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Anteroposterior (AP) diameter
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 Slightly with age and prematurely with COPD
Barrel Chest –
In the normal adult, the AP
diameter of the chest is about
half its lateral diameter (1:2).
When the patient has barrel
chest, the ration is (1:1) associated with emphysema
Bedside Assessment of the Patient

Inspection
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Abnormal Chest Configuration
Pectus excavatum
– funnel-shaped
depression over
the lower
sternum (aka:
“funnel chest”) associated with
restrictive lung
defects
Pectus carinatum
– forward
projection of
the xiphoid
process and
lower
sternum (aka:
“pigeon
breast”
Bedside Assessment of the Patient
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Inspection
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Abnormal Chest Configuration
Kyphosis
Scoliosis
A “hunchbacked”
appearance
caused by
curvature of the
spine
A lateral
curvature of the
spine that
results in the
chest protruding
posteriorly and
the anterior ribs
flattening out
Bedside Assessment of the Patient
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Inspection
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Abnormal Chest Configuration
Kyphoscoliosis
The combination of
kyphosis and
scoliosis – may
produce sever
restrictive lung
disease as a result
of poor lung
expansion
Bedside Assessment of the Patient
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Inspection
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Abnormal Chest Configuration
Scars
•Lobectomy
•Pnemonectomy
Bedside Assessment of the Patient
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Inspection
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Abnormal Extremity Findings
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Altered Skin Color
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Digital Clubbing
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Pedal Edema
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Distended Neck Veins
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Tracheal Deviation
Bedside Assessment of the Patient
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Inspection
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Abnormal Extremity Findings
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Altered Skin Color
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A general observation of the patient’s skin color should
be routinely performed
 Does the patient’s skin color look normal?
 Is the skin cold or clammy?
 Does the skin look ashen or pallid?
 Do the patient’s eyes , face, trunk, and arms have a
yellow, jaundiced appearance
 Is there redness of the skin (erythema)?
 Does the patient appear cyanotic?
Bedside Assessment of the Patient
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Inspection
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Abnormal Extremity Findings
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Altered Skin Color
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Central Cyanosis
Cyanosis – a blue-gray or purplish discoloration of the
mucous membranes, fingertips, and toes
 Occurs when 5 g/dl of the hemoglobin is reduced
(hemoglobin that is not bound with oxygen)
Observed in the lips and oral
mucosa of mouth - almost
always a sign of hypoxemia
Bedside Assessment of the Patient
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Inspection
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Abnormal Extremity Findings
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Altered Skin Color
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Peripheral Cyanosis
 Easily seen in the fingernails
 Becomes visible when the amount of hemoglobin in
the capillary blood exceeds 5-6 g/dL
 Mainly the result of poor blood flow, especially in the
extremities
 Influenced by temperature
 Together with coolness of the extremities, peripheral
cyanosis is a sign of poor perfusion
Bedside Assessment of the Patient
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Inspection
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Abnormal Extremity Findings
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Digital Clubbing
 Enlargement of terminal
phalanges of the fingers and toes
 Significant manifestation of
Cardiopulmonary disease
 Angle of the fingernail to the nail
base increases, nail bed feel
“spongy”
Bedside Assessment of the Patient
 Inspection
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Abnormal Extremity Findings
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Digital Clubbing
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Interstitial lung disease
Bronchiectasis
Various cancers (including lung
cancer)
Congenital heart problems that
cause cyanosis
Chronic liver disease
Inflammatory bowel disease
Bedside Assessment of the Patient
 Inspection
 Abnormal Extremity Findings
 Pedal Edema
 Swelling of the lower extremities
 Commonly seen in patients with:
 Congestive Heart Failure (CHF)
 Cor pulmonale (right-sided heart failure)
 Liver disease
 Kidney disease
Bedside Assessment of the Patient
 Inspection
 Abnormal Extremity Findings
 Pedal Edema
 Firmly depress the skin for 5
seconds then release
 Normal – no indentation
 May see some pitting if person
has been standing all day or is
pregnant
 If pitting is present
 Subjective scale
 1+ (mild, slight depression)
 4+ (severe, deep depression)
Bedside Assessment of the Patient
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Inspection
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Abnormal Extremity Findings
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Capillary Refill
 Pressure is applied to the nail
bed until it turns white,
indicating that the blood has
been forced from the tissue
(blanching). Once the tissue has
blanched, pressure is removed
 The health care provider will
measure the time it takes for
blood to return to the tissue,
indicated by a pink color
returning to the nail
Bedside Assessment of the Patient
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Inspection
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Abnormal Extremity Findings
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Capillary Refill
 Caused by reduced cardiac output
and poor digital perfusion
 Blanch times that are >2 seconds
may indicate one of the following:
 Dehydration
 Shock
 Peripheral vascular disease
(PVD)
 Hypothermia
Bedside Assessment of the Patient
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Inspection
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Abnormal Extremity Findings
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Capillary Refill
 Normal refill
 Infant
Bedside Assessment of the Patient
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Inspection
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Abnormal Extremity Findings
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Capillary Refill
 Delayed refill
 Infant
Bedside Assessment of the Patient
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Inspection
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Abnormal Extremity Findings
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Distended Neck Veins
 In patients with cor pulmonale, severe flail chest,
pneumothorax, or pleural effusion, the major veins
of the chest that return blood to the right heart may
be compressed. When this happens, venous
return decreases and central venous pressure
(CVP) increases. This condition is manifested by
distended neck veins (also called jugular vein
distention – JVD)
Bedside Assessment of the Patient
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Inspection
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Abnormal Extremity Findings
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Distended Neck Veins (JVD)
Bedside Assessment of the Patient
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Inspection
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Abnormal Extremity Findings
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Distended Neck Veins (JVD)
 Elevate head of patient’s
bed to 45
 Blood column should only
be a few centimeters above
the clavicle
 If venous pressure is
elevated, neck veins may
be distended as far as the
jaw
Bedside Assessment of the Patient
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Inspection
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Abnormal Extremity Findings
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Tracheal Deviation
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Trachea normally in middle of neck
 Directly below the center of the suprasternal notch
Shifts toward
 Collapsed lung
 Atelectasis
 Pneumonectomy
Shifts away
 Increased air (tension pneumothorax)
 Increased fluid (pleural effusion
 Increased tissue (tumor)
Bedside Assessment of the Patient
 Tracheal Deviation
 Tracheal shift
 Pneumonectory
Bedside Assessment of the Patient
 Tracheal Deviation
 Tracheal shift
 Pleural effusion
Bedside Assessment of the Patient
 Inspection
 Cough
 Most common symptom in patients with
pulmonary disease
 Occurs when cough receptors are stimulated
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Inflammation
Mucus
Foreign materials
Noxious gases
Bedside Assessment of the Patient
 Inspection
 Cough
 Characteristics
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Dry or loose
Productive or nonproductive
Acute or chronic
During day or night
Bedside Assessment of the Patient
Dry, loose, productive … ?
Bedside Assessment of the Patient
 Inspection
 Sputum Production
 Airway disease may cause mucus production
 Phlegm – mucus from the tracheobronchial tree, not
contaminated by oral secretions
 Sputum – mucus from the lung but passes through
the mouth
Bedside Assessment of the Patient
 Inspection
 Sputum Production
 Terminology associated the sputum
 Purulent – sputum that contains pus (bacterial
infection – thick, colored, sticky)
 Fetid – foul smelling sputum
 Mucoid – clear, thick sputum
Bedside Assessment of the Patient
 Inspection
 Sputum Production
 Recent changes in the
color, viscosity, or
quantity or sputum
produced are often
signs of infection and
must be documented
and reported to the
physician
Bedside Assessment of the Patient
 Inspection
 Hemoptysis; coughing up blood or blood-streaked
sputum from the lungs
 Massive - > 300 ml over 24 hours
 Bronchiectasis
 Lung abscess
 Acute or old tuberculosis
 Nonmassive - < 300 ml over 24 hours
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Infection of airways
Lung cancer
Tuberculosis
Trauma
Pulmonary embolism