Medical Conditions I-DPTR 5301
Comprehensive Skills Outline
I.
There will be several case scenarios for the competency.
II.
Each student will have 15 minutes for the exam and 5 minutes to receive feedback
from the instructor – 20 min total per student.
III.
When you draw a case scenario, you will be asked to explain and perform the
examination and/or intervention techniques as outlined in the case.
IV.
The rubric will provides an “overview” of the grading that will be used for the
competency (see page 2-4).
V.
For percussion/postural drainage, the instructor will tell you the diagnosis and area
of the lung which needs to be addressed. You will be expected to assess breath
sounds and “diagnostic” percussion before your intervention and after your
intervention as indicated by the case.
VI.
For each scenario where the stethoscope is needed, you will be expected to “listen”
with the diaphragm (breath sounds and normal heart sounds) and the bell
(abnormal heart sounds).
VII.
For BP, you will be expected to perform the technique “by the book” – see below:
assess the radial pulse and determine the radial occlusion pressure; deflate the cuff
fully, identify the brachial pulse and then re-inflate the cuff to 30 mm Hg above the
point where the radial pulse was occluded. Deflate the cuff in a controlled manner
and determine the BP. Repeat if necessary (wait 1-2min btw)
VIII.
For cough or breathing techniques, your instructor will tell you which technique she
would like for you to perform so be prepared to demonstrate any of them.
IX.
The scenarios can be either inpatient or outpatient so please practice with having
your partner in gowns or in an outpatient setting where a patient may be wearing a
tank top/jog bra.
X.
We will use the dual stethoscopes for BP, heart and lung sounds so please practice
with these. They are in 3400 in the cabinet beside the sink, which should be
unlocked. If you have problems accessing the stethoscopes, please let me know.
XI.
Please wear “lab attire” since access to the chest wall/ thorax is necessary
XII.
Please bring a watch with a second hand which allows you to assess HR and RR.
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Example of Grading Rubric
General – Communication
1. ______ Introduces self to patient
2. ______ Explains overview of encounter
3. ______ Obtains Patient Consent
4. ______ Uses patient appropriate language
General - Positions and drapes the patient as needed
1. ______ Maintains modesty of patient
2. ______ Appropriate positioning
3. ______ Makes area of body available for examination/intervention
Breath Sounds
1._______ Knows to use diaphragm directly on skin
2._______Student is systematic and uses proper anatomical positions – e.g.: auscultates at
least 1 spot for each lobe bilaterally; listens top to bottom & left to right for comparison

Auscultation
o Listening Techniques/ Procedures:
 Sit patient up; roll patient – don’t just listen for the convenient sounds
 Breathe deep through mouth
 Stethoscope on skin
 Systematic comparison of L and R, and all lobes (goal is to auscultate at least
3-4 spots looking for SYMMETRY BILATERALLY)
4._______Listens at each spot, full cycle of inspiration & expiration
5._______Can explain normal breath sounds (bronchial (tubular/ tracheal); bronchovesicular;
and vesicular) and knows where each should usually be auscultated
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6. ______ Can explain abnormal breath sounds (e.g.: crackles, wheezing) particularly in the
patient scenario provided (e.g.: surgical patient versus hypersecretion of mucus versus
pneumonia …etc.).
o Tracheal/Bronchial/Tubular BS

 Over Trachea
 Loud, high pitched, harsh
 E>I w/ short pause
 Heart in other location = abnormal (lung = consolidation (PNA))
o Bronchovesicular BS

 Sternum, scapula, anterior RUL
 I=E duration & loudness, no pause
 More muffled than bronchial
o Vesicular BS

 Lung periphery
 I>E
 Medium pitch and loudness
o Abnormal Breath sounds
 Bronchial or bronchovesicular in vesicular or more peripheral area
 consolidation, fluid
 Fluid transmits better than air
 Wheeze
 Hear on expiration
 Smaller airways = high pitched, larger = low pitched
 Caused by narrowed airways from secretions, edema, bronchospasm
(airway collapsing when it should be open)
 Crackles
 Discontinuous notes “bubbling” “pop” “fizz”
 Hear on inspiration
 Large airways = low pitch = “coarse”, small = high pitch =
“fine/Velcro”
 Diminished or absent BS
 Hyperinflation (air trapping), air/fluid/blood between lung and chest
wall, airway blockage (mucus, tumor, foreign body), obesity

Other info…
o
Normal I:E ratio = 1:2, obstructive = 1:3 or greater
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o
o
Breath patterns

Chyne-Stokes breathing: abnormal pattern w/ oscillation of ventilation between apnea and tachypnea w/
crescendo-decrescendo pattern in depth of respiration (HF, CVA, TBI, brain tumor)

Kussmaul: consistent very deep breathing pattern at normal or increased rate (severe metabolic acidosis, form of
hyperventilation)
Fremitis

Tactile Fremitis = palpable vibration produced during breathing cause by partial airway obstruction

Mucus

Secretions in airway

Bronchial hyperreactivity/constriction, tumor

Vocal fremitus

Increased = consolidation, large airway secretions, pulmonary edema

Decreased = pneumothorax, pleural effusion
Heart Sounds
1.________Knows four locations (Aortic; Pulmonic; Tricuspid; Mitral)
(1)
(2)
(3)
(4)
Aortic 2nd right ICS, right sternal border
Pulmonic 2nd left ICS, left sternal border
Tricuspid 5th left ICS, left sternal border
Mitral 5th left ICS, mid clavicular line
2.________Uses diaphragm for S1, S2; bell for abnormal heart sounds (S3; S4; murmurs)
3.________Can explain what causes S1, S2


S1 = closure of AV valve
S2 = closure of atrial semilunar valve
4.________Can explain what causes S3


S3: CHF – early diastolic sound = after S2 preceding S1
o S3 = HEART FAILURE (if managed well won’t hear this)
o Low compliance of ventricles – S3 caused by crashing of blood into ventricles
S4: s/p MI; HTN
o S4 Happens very very late in diastole (just before S1)
o Turbulence in atrium causing swishing but still caused by decreased compliance of the
ventricles
Blood Pressure:
1. _______ Assess the radial pulse and determine the radial occlusion pressure
2.________ Deflate the cuff fully, identify the brachial pulse and then re-inflate the cuff to 2030 mm Hg above the point where the radial pulse was occluded.
3. _______ Positions arm at level of heart & deflates the cuff in a controlled manner to
determine the BP.
4.________Repeat if necessary
Pulse palpation
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1._______Can identify radial, carotid, dorsalis pedis pulses

Check bilaterally, only 1 carotid at a time.
2._______Knows to extend time of palpation due to irregularity of rhythm if assessing pulse
rate

If irregular must assess apical pulse, and must assess for longer duration (30s-1min)
3. _______Can describe “quality” of pulse (regular/ irregular; strong, normal, thread)





+4 = bounding
+3 = full, increased
+2 = normal
+1 = diminished, weak
0 = absent (thread)
Percussion (diagnostic)
1._______ Uses proper technique (see picture)
Snap wrist
At least 3-4 in front
At least 3-4 in back
Must make sure you assess upper, middle and lower. (back, side and front)
2._______ Can determine differences between normal resonance, hyperresonance (tympanic)
and dullness
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o (diaphragm descends to ~T7-T12)
o Cause of changes in percussion
 Tympany
 Pneumothorax
 Air trapping (COPD)
 Dullness
 Consolidation (PNA)
 Atelectasis
 Pleural effusion
Chest wall excursion
1._______ Assess in 3 places (see picture from lab PPT); can also asses laterally for anteriorposterior excursion
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
Upper chest – should feel pump handle
2. ______ Can offer hypotheses for chest wall asymmetry (e.g.: compliance changes; muscle
guarding; pain …etc.)
•
•
Deviates Towards
• Atelectasis
• Fibrosis
Deviates Away
• Pleural Effusion,
•
Tension Pneumothorax
•
(usually fatal) = hole in lung and there is no place for that air to go – no external injury, so air escapes
from lung into interpleural space (disrupts pressure induced cardiac filling (R atrium, etc.)
1) Sides moving equally? Why not?
a) Hemidiaphragm/paralysis
b) Pneumothorax
c) M splinting
d) Reduced compliance (disease/surgery/scoliosis)
e) PNA
Airway Clearance Techniques (ACT) - Postural drainage, chest wall percussion & vibration
1._______Student can explain rational behind positioning and ACT
Each position requires > 5min
2._______Demonstrates proper body mechanics for chest wall percussion (therapeutic):
cupped hands (no slapping), primary motion from elbows and wrists; watch your back! Uses
towel layer or sheet or shirt- do not percuss directly on patient’s skin
•
•
performed throughout whole respiratory cycle – inspiration and expiration
Perform for at least 5min
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•
•
Precautions: osteoporosis, thin skin (cortisteroids) , blood thinners, PAIN, recent pacemaker
ABSOLUTE CONTRAINDICATION – pulmonary hemmorage, unstable spine, consider head injury
(increase in intracranial pressure), consider pulmonary embolism, consider recent incision for
local contraindication
3. _______Demonstrates proper body mechanics for vibration: as vertical as possible over
patient, get feedback from patient (i.e. have the patient say “eeeee”) when doing technique
•
•
•
Performed only on expiration
Deep breath, hold for ~2sec, say “Eeeeee” on expiration as PT vibrates.
Continue until remove secretions (decrease or remove crackles), or patient can no longer
tolerate. (4-5 breaths)
 Creates external pressure and vibratory force through lungs to airways to promote
movement of secretion
4. ______ Can describe and perform alternative interventions to assist with airway clearance
(deep breathing/ incentive spirometry (role: open alveoli via pores of cone/lamberts canals);
assisted cough techniques; lateral costal breathing; therapeutic exercises (UE/ LE/ mobilization
…etc.)





Huff Cough
 Step 1: Controlled (diaphragm) breathing through nose x 2-3 breaths
 One hand on upper and one hand on lower chest, assume/feel normal breathing
 Abdomen expansion
 Can provide pressure to thorax to teach.
 Step 2: Hold breath x 2-3 seconds (inspiratory hold)
 Step 3: Forceful expiration with “open glottis”
 Max expiratory flow = max airway clearance
Active Cycle of Breathing (ACB)
o Step 1: Controlled (diaphragm) breathing through nose x 2-3 breaths
o Step 2: Deep breathing through the nose followed by a breath hold x 2-3 seconds (inspiratory
hold)
o Step 3: Huffing
o Step 4: Repeat
o Hazards
 Worsening SOB, hopoxemia, pain/injury to chest/spine, dysrhythmia, nausea/vomiting,
bronchospasm
Providing some pressure upward/inward (scooping) abdomen on expiration, can help activate
diaphragm (provides stretch)
Assisted Cough Techniques
o Heimlich Cough Assist/ “Quad” cough
 Hand distal to xiphoid process but superior to umbilicus
 Coordinate with breathing pattern – “thrust” with onset of expiration/cough
Costophrenic
o Hands on costophrenic angles of lower ribs (lateral)
o Follow breathing pattern
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o
As patient is beginning cough, apply pressure downward and medially
 Increasing abdominal content pressure.
Indications/Goals for Airway Clearance
 Incications
o >30mL sputum/day
o Hypersecretion mucus
o Ineffective mucociliary clearance
o Ineffective cough
o Immobility & weakness
o Dysphagia/aspiration/gastroesophageal reflux
 Goals
o Prevent accumulation, improve mobilization of secretions
o Improve breathing through relaxation
o Reduce symptoms of dyspnea
o Improve CP Ex tolerance
 Outcome assessment
o Increase or decrease sputum, improve symptoms, improve breath sounds, improve
SpO2, improve CXR.
Breathing Exercises and Breathing Retraining
1. ______ Can describe and perform breathing exercises including diaphragm breathing, deep
breathing/ incentive spirometry; lateral costal breathing; segmental breathing
2. ______ Can describe and perform breathing retraining strategies including diagphram
breathing combined with progressive postures/ mobilization – pacing of activities; pursed lip
breathing



1. Facilitation of diaphragm
 Semi fowler position; knees bent; neutral spine ( posterior pelvic tilt); abdominals
“relaxed”
 Sniffing
i. Ask person to sniff (x3) - may facilitate diaphragm activity
ii. After accomplishes the sniff, ask person to breath out slowly.
 “Scoop Technique” (s)
i. Place hand over umbilicus and follow breathing pattern; apply gentle
“overpressure” during expiration
ii. At the end of expiration, give a slow stretch and “scoop” hand up and into
thorax
iii. Ask patient to “breathe into my hand”
 Coordinate diaphragm breathing with activities (supinesittingstanding ambulation)
2. Pursed lip breathing
3. Segmental & Lateral Costal Breathing techniques
 Lateral costal: place hands on lower ribs, laterally
a. Use hands and quick stretch to promote breathing in a certain region
b. Ex: atelectasis – want to augment airflow in this region
 Segmental: place hands over desired lung region – specific region
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

o If person sitting up can use your body as the “table top” laterally
o Not resisting on inhalation.
o Apply quick stretch on max expiration
Ask patient to breathe into my hands – providing biofeedback.
a. Don’t remove hand placement b/c want to provide that feedback
Add PNF techniques such as “quick stretch”
Cardiac &/ or Pulmonary Rehabilitation Principles (exercise prescription)
1. ______ Student can create & implement an exercise prescription for patients/clients with
primary cardiac &/or pulmonary disorders including all components: mode; intensity;
frequency; duration; progression


Cardiac rehab
o Exclusions
 Unstable angina
 Class IV heart failure
 Uncontrolled sustained tachyarrhythmias or bradyarrhythmias
 Symptomatic aortic or mitral stenosis
 Severe pulmonary hypertension
 Conditions that could be aggravated by exercise:
 Systolic BP >200 mm Hg or Diastolic BP > 100 mm Hg
 Suspected myocarditis or pericarditis
 Recent systemic or pulmonary embolus
 Infectious disease processes
o Phase 1:
 Evaluate physiologic response to self-care/ambulation activity
 Goal 3-5METS
 HRrest + (20-30bpm)
o Phase 2:
 Outpatient
 Typical Exercise Rx = HR rest + [(0.5 to 0.85)x(HR max - HR rest)]
 Lifestyle change – improve CV/P fitness safely, functional
Pulmonary Rehab
o Mode
 Aerobic – large muscle groups, rhythmic,
 Inspiratory m training
 Strength training
 LE
 UE
 UE/LE isotonic
o Intensity – SYMPTOM PARAMETER
 %HRmax 60-90% HRmax or 50-85% VO2max
 RPE
10
o
o
o
o
 High intensity (start 60%  goal > 80% peak work rate)
Duration
 Goal 30-40min continuously
 Intervals
Frequency
 Goal: 3-5x/week
 If reduced duration/intensity  increase frequency
Progression – SYMPTOM BASED
Assessment
 HR/ECG, BP, RPE, SpO2, Breath Sounds, (RR)
 Peak flow/spirometer, weight, JVD, heart sounds
 Pulmonary rehab does not change mortality – the number one
change is symptoms. – no consistent improvement in pulmonary
function.
 Ex capacity, m strength, dyspnea, fatigue, QOL
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Pulm pathology Summary
 Pulmon
o Restrictive lung disease
 Reduced expansion lung/chest wall
 Decreased compliance
 Dyspnea, tachypnea, hypoxemia, cyanosis (poor gas exchange)
 Types
 Pneumonia
o Affects alveolar spaces and interstitial tissue
 Atelectasis
 Pneumothorax
 Pleural effusion
 Pulmonary Edema
 Idiopathic pulmonary fibrosis (pulmon interstitial disease)
 Pulmonary interstitial diseases
o 2nd ary pulmon HTN, R heart failure (destruction
vasculature)
o Up FEV1
o Obstructive lung disease
 Reduced airflow during forced expiration from
 Airway narrowing
 Loss elastic recoil
 Dyspnea, wheezing, reduced ex capacity, +/- mucus production
 Types
 COPD
o Hyperinflation
o Chronic bronchitis, emphysema, and reactive airway
disease
 Emphysema
o Pink puffer
o loss elasticity, destruction of air space and alveolar
walls, wt loss
o Hyperinflation, hypertrophy accessory m, clubbing
digits, wheezing
 Bronchiectasis/Cystic Fibrosis
o Lots of mucus  plugging  bronchiectasis and airway
obstruction
 Chronic bronchitis
o Blue bloater
o Sputum production
o R heart failure, DOE, dyspnea, hypercapnia,
hypoxemia, cyanosis,
o Pulmonary Exam
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






Accessory m. usage
WOB
Chest wall/thorax (scoliosis)
Skin – incision/scar/bruises
Cough
Sputum
Palpation
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Inspection (Observation)
Anterior view of the thorax
~ Rib # 4
RUL
LUL
RML
RLL
LLL
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Posterior view of
the thorax
~ Rib # 4-6
LUL
RUL
LLL
RLL
Diaphragm position:
•
Approx. T7 (@ FRC) & T10
(following VT)
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