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148 Cards in this Set
- Front
- Back
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What are the 4 components of the chest examination?
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1) Inspection
2) Auscultation 3) Palpation 4) Percussion |
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During inspection, what should the therapist be looking for?
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Problems that were previously unidentified
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What are the 4 portions of the inspection?
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1) Evaluate patient's general appearance
2) Closely inspect head and neck 3) Closely inspect the chest 4) Evaluate breathing, cough, and sputum |
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After evaluating their general appearance we should assign a patient to 1 of these 7 stages of consciousness:
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1) Alert - pays attention to instructions
2) Automatic - irritable, impaired judgment, retains instructions poorly 3) Confused - disoriented, illogical, responds to simple commands 4) Delirious - totally irrational, aggravated, hostile, generally uncooperative 5) Stuporous - unresponsive to environmental stimuli, incontinent 6) Semicomatose - unconscious but responsive to painful stimuli 7) Comatose - unconscious and unarousable |
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What 5 things should you be looking for during the evaluation of the extremities?
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1) Nicotine stains - indicates they're a heavy smoker
2) Clubbing of fingers or toes - good indication of cardiopulmonary disease 3) Painful, swollen joints - may indicate pseudohypertrophic pulmonary ostoarthropathy 4) Asterixis (flapping tremor of wrists when arms are extended) - suggests hypercapnia (excessive CO2 in blood) 5) Bilateral pedal edema - indicative of R sided heart failure |
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What specific symptom should you be looking for during the evaluation of the head and neck?
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Plethora (overfullness of blood vessels)
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What 4 things are you looking for during the evaluation of the unmoving chest?
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1) Condition of skin
2) Shape & symmetry of chest 3) Normal ribs and intercostal spaces 4) Musculature development |
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How can you tell that the ribs and intercostal spaces are normal during your examination?
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rib angles <90˚ and intercostal spaces are broader posteriorly than anteriorly
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What abnormalities are you looking for during evaluation of the UNMOVING chest to assess the shape and symmetry of the chest?
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1) Pectus carinatum
2) Pectus excavatum 3) Barrel chest deformity (common in obstructive pulmonary disease) |
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What conditions of the skin are you looking for during your evaluation of the UNMOVING chest?
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Incisions, scars, or any sign of trauma
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What are you specifically looking for when assessing musculature development of the UNMOVING chest?
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Trapezius hypertrophy associated with chronic dyspnea
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How do you evaluate the MOVING chest?
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1) Assess ventilatory rate (normal = 12-20 bpm)
2) Fever 3) Ratio of inspiratory and expiratory time 4) Noises of breathing |
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Fever will increase breath rate by how many breaths per minute for every 1˚F of temperature increase?
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4 breaths per minute
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What is the normal ratio of inspiratory to expiratory time? What about in those with obstructive lung disease?
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Normal: expiration is twice as long as inspiration (1:2 ratio)
Diseased: 1:4 ratio |
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What are the 4 noises of breathing?
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1) Stridor - crowing sound during inspiration (indicative of upper airway obstruction)
2) Stertor - snoring noise caused by tongue falling back into lower palate 3) Expiratory grunting - physiological attempt to prevent premature airway collapse 4) Gurgling - heard during both ventilatory phases ("DEATH RATTLES") |
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What is apnea?
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Absence of ventilation
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What is fish-mouth?
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Apnea with concomitant mouth opening and closing
Associated with neck extension and bradypnea |
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What is eupnea?
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Normal rate, normal depth, regular rhythm breathing
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What is bradypnea?
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Slow rate, shallow or normal depth, regular rhythm
Associated with drug overdose |
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What is tachypnea?
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Fast rate, shallow depth, regular rhythm
Associated with restrictive lung disease |
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What is hyperpnea?
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Normal rate, increased depth, regular rhythm breathing
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What is Cheyne-Stokes (periodic)?
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Increasing then decreasing depth, periods of apnea interspersed; somewhat regular rhythm
Associated with critically ill patients |
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What is Biot's?
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Slow rate, shallow depth, apneic periods, irregular rhythm
Associated with CNS disorders (e.g. meningitis) |
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What is apneustic?
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Slow rate, deep inspiration followed by apnea, irregular rhythm
Associated with brainstem disorders |
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What is prolonged expiration?
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Fast inspiration, slow and prolonged expiration yet normal rate, depth, and regular rhythm
Associated with obstructive lung disease |
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What is orthopnea?
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Difficulty breathing in postures other than erect
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What is hyperventilation?
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Fast rate, increased depth, regular rhythm
Results in decreased arterial CO2, tension Called "Kussmaui breathing" in metabolic acidosis Also associated with CNS disorders (e.g. encephalitis) |
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What is psychogenic dyspnea?
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Normal rate, regular intervals of sighing
Associated with anxiety |
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What is dyspnea?
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Rapid rate, shallow depth, regular rhythm
Associated with accessory muscle activity |
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What is doorstep?
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Normal rate and rhythm; characterized by abrupt cessation of inspiration when restriction is encountered
Associated with pleurisy |
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How do you evaluate the symmetry and synchrony of breathing?
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1) Compare motion of 1 hemi-thorax to the other side (may find asynchronous motion in hemiplegic patients)
2) Flail chest deformity may result in expansion of one part of the chest while another is retracting |
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How do you evaluate the muscles of breathing?
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1) Observe deviations in men and children from normal diaphragmatic breathing
2) Observe deviations in women from normal costal breathing 3) Observe accessory inspiratory or expiratory muscle use |
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What should you look for while evaluating a patient's speech?
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1) Dyspnea of phonation (causes them to have limited word patterns)
2) Poor voice control - muscular incoordination is common in CNS disorders (they won't be able to maintain monotony of voice) |
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What does bad breath indicate?
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An infection of the mouth or respiratory tract
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What should you look for when evaluating a cough?
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Persistent vs. occasional
Dry vs. productive |
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What are you looking for when assessing sputum?
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Quantity, color, and consistency
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What does red sputum indicate?
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Blood
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What does rust-colored sputum indicate?
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Pneumonia
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What does purple sputum indicate?
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Neoplasm
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What does yellow or green sputum indicate?
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Infection
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What does pink sputum indicate?
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Pulmonary edema
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What does flecked sputum indicate?
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Carbon fibers
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What qualities should you be looking for when assessing the consistency of sputum?
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1) Thin watery
2) Gritty 3) Thick mucous 4) Layered |
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Define: the act of listening for sounds in the body for the purpose of ascertaining the condition of the lungs
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Auscultation
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What is a normal vesicular breath sound?
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Rustling
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Intensity of rustling increases rapidly reaching a maximum shortly after what has begun?
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Inspiration
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What do bronchial or tubular breath sounds sound like?
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Loud and harsh
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When are bronchial or tubular breath sounds absent?
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Between inspiration and expiration
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What are abnormal breath sounds?
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1) Crackles or rales (nonmusical sounds) - found at the end of inspiration; may represent abnormal lung inflation
2) Rhonci or wheezes (continuous and musical) - suggest a rigid airway |
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What are the 6 steps of a respiratory examination?
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1) Instruct patient to sit forward or in a side-lying position
2) Expose anterior chest to permit evaluation of upper and middle lung zones 3) Have patient breathe in and out through mouth 4) Evaluate at least 1 breath in each pulmonary segment looking at intensity, pitch, and quality of breath sounds 5) Proceed cranially-to-caudally in a systematic manner 6) Proceed to the back (once anterior chest exam is done) |
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What should treatments administered to increase alveolar ventilation do to tidal ventilation and dead space ventilation?
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Increase tidal ventilation
Decrease dead space ventilation or Both |
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What should treatment administered to increase ventilation and oxygenation do to PaCO2 and PaO2?
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Decrease PaCO2
Increase PaO2 |
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What should be included in treatments to increase ventilation and oxygenation?
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Positioning techniques
Breathing exercises |
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What types of breathing exercises can help increase ventilation and oxygenation?
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diaphragmatic
pursed lips segmental low frequency sustained maximal |
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Different positions may do what to ventilation?
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Increase
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Diaphragmatic breathing exercises improve what movements of the diaphragm?
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descent during inspiration
ascent during expiration |
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How can diaphragmatic ascent be improved during exhalation?
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contract the abdomen
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What is the ideal position, initially, for diaphragmatic breathing?
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comfortable, with hips and knees flexed to relax abdominal and hamstring muscles
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When teaching diaphragmatic breathing, when and where do you apply counter pressure?
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over the patient's dominant hand, over the abdomen, just before inhalation
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What are progressions for diaphragmatic breathing?
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during sitting, standing, walking
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What do some studies suggest that diaphragmatic breathing helps to improve?
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lower lung ventilation
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Do studies suggest that diaphragmatic breathing results in better oxygenation?
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Yes
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Pursed lip breathing is used extensively by which types of pulmonary patients?
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COPD
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What hand placement by the therapist is important during pursed lip breathing and why?
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Over the abdomen to detec abdominal contraction
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What is segmental breathing known as?
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localized breathing
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When do you apply firm pressure during segmental breathing?
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at the end of the patient's expiratory maneuver
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What are low frequency breathing exercises?
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teaching patients to breathe deeply with slow, deep breath
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How long do you hold a maximal inspiration during sustained maximal breathing exercises?
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3 seconds
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What are the two main treatments administered to reduce oxygen consumption?
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reduce the work of breathing
reduce general body work |
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What is the best way to reduce the work of breathing?
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eliminate accessory muscle activity
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Does a forward leaning posture make it easier or more difficult to breathe?
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Easier - eliminates the work of ventilation
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What is an example of a work adjustment to reduce general body work?
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Sit to brush teeth instead of standing
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What causes accumulation of secretions?
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decreased normal secretion clearance by mucociliary transport
decreased effective cough |
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What does postural drainage assist with?
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movement of mucus for expiration by coughing
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What is the proper cough sequence for enhancing coughing?
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1. Inspire maximally
2. Close glottis 3. Bear down by tightening abs, gluts, dhoulder depressors 4. Cough no more than 2 times during expiratory phase 5. Splinting with a pillow may be used for patients with incisions |
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How can exercise tolerance be improved?
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By prescription of a cardiovascular endurance program
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What is most pain associated with respiratory problems due to?
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Incisions
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What is the only contraindication for the use of TENS for pain near incision?
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skin irritation
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When evaluating chest motion, how much separation is normal between upper lobes?
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at least 1 inch
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How do you perform an upper lobe motion evaluation?
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1) Face the patient
2) Drape to expose the upper lobes of both lungs 3) Place palms firmly over anterior aspect of chest 4) Hook fingers over upper traps 5) Draw hands down and medially until thumbs meet in midline 6) Relax elbows and shoulders 7) Instruct patient to inspire 8) Allow hands to reflect the movement of the lobe of the lung underneath |
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How do you perform a R middle & L inguinal lobe motion evaluation?
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1) Face patient
2) Drape to expose right lung 3) Hook fingers over posterior axillary folds 4) Place palms firmly against chest wall 5) Draw skin medially until thumbs meet in midline 6) Relax elbows and shoulders 7) Instruct patient to inspire 8) Allow hands to reflect movement of the lobe underneath |
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How do you perform a lower lobe motion evaluation?
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1) Position patient with back towards you
2) Hook fingers around anterior axillary fold 3) Draw skin medially until extended thumbs meet in midline 4) Relax elbows and shoulders 5) Instruct patient to inspire 6) Allow hands to reflect movement of lobes underneath |
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What is fremitus?
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Vibration produced by either the voice or secretions which are transmitted to the chest wall
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How do you evaluate fremitus?
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1) Place palms lightly in symmetrical areas of the chest
2) Instruct patient to say "99" 3) Compare intensity of vibrations detected by each hand in the apical, anterior, lateral, and posterior areas of the chest |
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When do you evaluate fremitus?
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During quiet breathing and speech (normally, equal and moderate vibrations are perceived during speech)
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When is fremitus abnormal?
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When it is increased or decreased during speech, or present during quiet breathing
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What does increased fremitus indicate?
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A loss or decrease in ventilation (decreased air in the lungs)
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What does decreased fremitus indicate?
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A gain in the amount of air within the chest
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How do you evaluate the scalenes?
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Palpate the scalenes during quiet breathing (they should be inactive)
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What does it mean if the scalenes are active during normal breathing?
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It indicates that the tertiary muscles of inspiration are functioning and the work of breathing is increased
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Is chest pain from musculoskeletal problems common?
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Yes - called costochondritis
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Where is costochondritis pain localized to?
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The anterior chest and is aggravated by deep breathing
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What is angina?
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A crushing tightness that may radiate to the jaw and L arm and is aggravated by exercise
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Chest pain associated with a tumor is commonly accompanied by what?
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A cough and hemoptysis
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Disk and nerve root pain follow what kind of pattern?
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Dermatomal distribution
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How do you evaluate diaphragmatic movement?
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1) Have patient supine
2) Expose costal margins of anterior chest 3) Place both hands lightly over the anterior chest wall with thumbs over costal margins so that the tips almost meet at xyphoid 4) Instruct patient to take a deep breath 5) Allow thumbs to move with the breath |
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Equal upward motion of both costal margins normally occurs when?
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During inspiration
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Inward motion of costal margins has been associated with what?
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A poor prognosis for the survival of patients with COPD
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How does percussion allow the therapist to evaluate the patient?
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It enables the therapist to determine changes in lung density and determine the extent of diaphragmatic motion
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designates type, intensity, duration, frequency and progress of physical activity
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Exercise prescription
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Exercise requires what objective measurements of physical activity?
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1.HR
2. ECG 3. arterial BP 4. functional capacity |
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What types of activity should we use for cardiorespiratory fitness for asymptomatic adults?
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1. Uses large muscle groups
2. Maintained for prolonged period 3. Rhythmical and aerobic in nature |
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What intensity should we use for cardiorespiratory fitness for asymptomatic adults?
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65% to 90% of max HR
50% to 85% of VO2 max |
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What duration should we use for cardiorespiratory fitness for asymptomatic adults?
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15-60 min
Dependent on intensity Lower to moderate intensity for longer duration for non-athletic adults |
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What is the frequency of of activity for cardiorespiratory fitness for asymptomatic adults?
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3-5 days per week
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What is the rate of progression for cardiorespiratory fitness for asymptomatic adults?
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1. Occurs by increasing intensity or duration or combination of both
2. Most significant conditioning effect occurs in 1st 6-8 wks 3. Adjustment made based on patient's tolerance, new exercise test results or on performance during exercise session 4. Symptomatic patients will progress much slower |
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What are the 2 classifications of endurance exercises?
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Group #1- activity easily sustained with little variability in HR
Group #2- continuous exercise intensity not maintained |
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Give some examples of group 1 endurance exercises
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walking, jogging, swimming, cycling, etc
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Give some examples of group 2
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dancing, mountain climbing, sports
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What is the advantage of group 2 endurance activities
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less boredem and gets mind off problems
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When is group 1 endurance activities recommended?
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during early stages of conditioning
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Who are group 1 endurance activities recommended for?
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asymptomatic sedentary adults, takes 6-10 wks to prepare patient for most games and/or activities
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What is the most difficult problem in designing an exercise program?
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Exercise intensity
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Participant should feel rested within ___ following exercise session
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1 hr
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Intensity is prescribed by:
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1. HR
2. Rate of perceived exertion 3. MET level |
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220 - age=
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maximal HR
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Maximal heart rate is determined by maximal _______ _______.
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exercise intensity and is most accurate
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What is the target zone of HR for exercise intensity?
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65-90% of maximal HR
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RPE correlate highly with what?
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HR, VO2, ventilation rates, and blood lactate concentrations
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A rating of 12-13 RPE corresponds to ___% of maximal HR
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60
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A rating of 15 RPE corresponds to ___ % maximal HR
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90
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How do we use METs to calculate exercise intensity?
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1. determine functional capacity in METs
2. Calculate average MET conditioning intensity 3. Choose appropriate activity corresponding to MET level |
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What is the most common exercise duration time?
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20-30 min
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Conditioning from an exercise program is a result of ____________
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total energy expenditure TEP
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TEP=
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intensity of exercise x duration of exercise
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What is the exercise frequency for persons with <3 MET functional capacity
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5 min exercise session several times a day
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What is the exercise frequency for persons with 3 to 5 MET functional capacity
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1 to 2 daily sessions
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What is the exercise frequency for persons with 5 to 8 MET functional activity
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3x/wk on alternate days
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What are the 3 stages of endurance exercise progression?
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1. initial stage
2. improvement stage 3. maintenance stage |
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The initial stage of endurance exercises should include?
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1. light stretching, light calisthenics, low level aerobic activity
2. intensity should be 1 MET lower than what is prescribed 3. duration should be 10-15 minutes 4. frequency: 4-6 wks, 6-10 wks for CHD patients |
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The improvement stage of endurance exercises should include?
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1. intensity increased to target level
2. duration increased every 2 to 3 wks 3. CHD patient progresses more slowly; depends on their tolerance |
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The maintenance stage of endurance exercises should include?
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begins after 6 months
not interested in improving conditioning but maintaining fitness levels attained |
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excessive percent body fat
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obesity
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obesity is influenced by what 2 factors?
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genetic & behavioral factors
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What is the fundamental determinant of obesity?
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caloric intake
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obesity is associated with what three increased risks?
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HTN, diabetes,CHD
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Extreme caloric restriction results in what?
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weight loss of water and lean tissues
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Exercise induced negative caloric balance results in:
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weight loss of adipose tissue
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Energy expenditure of ____ kcal/session & _____ kcal/wk is recommended for both symptomatic and asymptomatic patients
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300 and 1000
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_____ kcal/session during 1st weeks of conditioning
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200
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_____ kcal/session attained in 8-12 wks
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300
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what are the flexibility principles for cardiac exercise prescription?
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1. maintenance of joint ROM
2. stretching exercise should not cause pain 3. at least 3x per wk |
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For cardiac exercise prescription is the frequency to gain muscle strength and flexibility?
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acquired by high resistance & low repetition exercises (5-7 reps; 3 sets)
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Muscle strength and flexibility exercises in cardiac pts result in _______ bp
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increased
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All candidates for cardiac rehabilitation should be clinically evaluated to determine?
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1. Whether patient is likely to benefit from exercise training
2. The patient's ability to return to employment 3. The success of current medical management 4. The amount of supervision and/or monitoring needed during the exercise session |
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Comprehensive cardiac rehabilitation should include:
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1. medical evaluation
2. prescribed exercise 3. risk factor modification 4. education 5. counseling and behavioral interventions |
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What are absolute contraindication to exercise training for cardiac pts
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1. unstable angina
2. uncontrolled CHF 3. dysrhythmias compromising hemodynamic status 4. uncontrolled hypertension 5. acute myocarditis 6. severe valvular stenosis 7. hypertrophic cardiomyopathy 8. acute pulmonary embolism or deep venous thrombosis |
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What are the characteristics of patients most like to benefit from continuous ECG monitoring during CR
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1. Severely depressed left ventricular function (ejection fraction <30%)
2. Restin complex ventricular arrhythmia 3. Ventricular arrhythmias that appear or increase w/ exercise 4. Survival of sudden cardiac death 5. Survival of MI complicated by CHF, cardiogenic shock, and/or serious ventricular arrhytmias 6. severe coronary artery disease and marked exercise-induced ischemia (ST depression greater than 2mm) 7. Inability to self-monitor HR (physical or intellectual impairment) |
