9/24/2017 5 Patient Assessment Skills To Crush The TMC-RRT Exam - Respiratory Therapy Programs

5PatientAssessmentSkillsToCrushTheTMCRRTExam
respiratorytherapyprograms.com /5patientassessmentskillscrushtmcrrtexam/
3/20/2016

Blausen.comstaff."Blausengallery2014".WikiversityJournalofMedicine.DOI:10.15347/wjm/2014.010.
ISSN20018762.Ownwork,CCBY3.0,https://commons.wikimedia.org/w/index.php?curid=27924395

5PatientAssessmentSkillsYouNeedToKnowToCrushTheTMCRRTExam!
by
RespiratoryTherapyPrograms

Physicalexaminvolvesobserving,palpating,percussing,andauscultatingthepatient.Allofthesemethodsrevealclues
tothesourceofthepatientsproblems.Physicalexamcluesareincludedinalargemajorityofquestionsontheboard
exams.KnowingphysicalexamterminologyandhowitrelatestoyourpatientwillserveyouwellontheTMCRRT
exam.
Palpation
Palpationinvolvesputtingyourhandsonthepatienttomeasurechestexpansion,palpatefortactilefremitus,and
assessfortrachealdeviation.

A.Chestexpansion
Evaluatechestexpansionbyplacingbothhandsonthepatientschestandmeasuringthedistanceeachhandmoves
apartduringinhalation.Symmetricalchestexpansiononbothsidesisnormal.
Asymmetricalchestmovementisabnormal.Commoncausesinclude:
1.Pneumothorax

2.Rightmainstemintubation

3.Pneumonia

4.Flailchestiscausedbyseverechestwalltraumasuchasmultiplebrokenribs.Flailchestcausesparadoxical
motionoftheaffectedsideascomparedtothenormalsideofthechest.
9/24/2017 5 Patient Assessment Skills To Crush The TMC-RRT Exam - Respiratory Therapy Programs

5.Seesawmovementoftheabdomenandchestoccurswhenthediaphragmfatiguessuchasoftenoccurswith
paralyzedpatients.Thisshouldnotbeconfusedwithflailchest.

Decreasedchestexpansionmaybeduetoneuromusculardiseasesortheresultofanalreadyhyperinflatedchest
duetoCOPD.
B.TactileFremitus
Fremitusisanotherwordforvibrations.Vibrationsfromthepatientsspeechareknownasvocalfremitus.Whenthe
clinicianfeelsthevibrationswiththeirhandswhilethepatientspeaks,thevibrationsbecomeknownastactilefremitus.
Thecliniciandescribesthevibrationsasincreased,decreased,orabsent.Vibrationsaretransmittedbetterthrough
consolidatedlungsthanclearlungs.
Increasedfremitusisassociatedwith:
1.Pneumonia
2.Lungtumors
3.Atelectasis
Decreasedfremitusisassociatedwith:
1.COPD
2.Pneumothorax
3.Pleuraleffusion
4.Obeseorverymuscularpatients
Rhoncialfremitusisassociatedwithsecretionsandcanusuallybeclearedwithacough.
C.TrachealDeviation
Understandingwhichdirectionthetracheashiftsinpatientswithpneumonia,pleuraleffusion,pneumothorax,or
atelectasiswillgreatlyincreaseyourchancesofpassingtheboardexams.Fortunately,therearetwosimplethingsto
rememberthatwillhelpyoudeterminewhatiscausingthetracheatoshift.
1.Lungproblemsoutsidethelung,suchaspleuraleffusionsorpneumothorax,pushthetracheaaway
2.Lungproblemsinsidethelung,suchaspneumoniaoratelectasis,pullthetracheatowardsthem.

DiagnosticChestPercussion
Percussingthechestwallproducesdistinctsoundsthathelpevaluatetheunderlyingtissue.

PercussionTechnique:
1.First,placeonlythemiddlefingerfirmlyagainstthechestandbetweentheribs.Strikethefirstjointofthemiddle
fingerwithyouroppositemiddlefingertip.
2.Next,evaluatetheintensity(loudness)andpitchwhilecomparingbothsidesofthechest.

Normalchestpercussionproducesaneasilyheardlowpitchedsoundwhenpercussed.Thisisknownasresonant.

Abnormalchestpercussion
Dullordecreasedresonanceoccurswhenthedensityinoraroundthelungincreases.Commoncausesinclude:

1.Pleuraleffusion
2.Pneumonia
3.Atelectasis
Hyperresonantlungsproducealoud,hollowsoundwhenpercussed.Thisoccursasaresultofexcessiveairtrapped
inthelungorpleuralspace.Commoncausesinclude:

1.Pneumothorax
2.COPD

ClickHereFor10FreeExamPracticeQuestionsWithThoroughExplanations
AuscultationOfTheLungs
Normalbreathsounds
Vesicularandbronchialbreathsoundsareconsiderednormalwhentheyareheardinthecorrectplace.
9/24/2017 5 Patient Assessment Skills To Crush The TMC-RRT Exam - Respiratory Therapy Programs

1.Vesicularbreathsoundsarequiet,lowpitched,softintensitysoundsheardovertheperipheral(outer)lungregions.
2.Bronchialbreathsoundsareharsh,loudsounds.Bronchialbreathsoundsareheardoverthelargeairwayssuchas
thebronchialtubesandtrachea.Bronchialbreathsoundsheardoverthelungbaseswouldsuggestaconsolidation
suchaspneumonia.

AbnormalBreathSounds
Breathsoundssuchasbronchialbreathssoundsheardoverthelungperipheryanddiminishedbreathsoundsare
consideredabnormal.Technically,thesebreathsoundsarenotconsideredadventitiousbecausetheyarenotadded
soundssuperimposedontopofnormalsounds.
1.Abnormalbronchialbreathsoundsreplacevesicularsoundswhenthatpartofthelungincreasesindensity.
Pneumoniamaycausebronchialbreathsoundswherevesicularbreathsoundsshouldbeheard.Ifatestquestion
statedbronchialbreathsoundsareheardinthelungbasesorperiphery,youwouldsuspectaconsolidationsuchas
pneumonia.
2.DiminishedbreathsoundsmaysometimesbereferredtoasdistantontheNBRCexam.Anythingthatcausesa
reductionofairfloworblocksthetransmissionofsoundthroughthelungmaycausediminishedbreathsounds.

Causesofdiminishedbreathsoundsmayinclude:

a.Pneumothoraxcausesairtoaccumulateinthepleuralspaceandreducesairmovementinthecollapsedlung.
Diminishedordistantbreathsoundsmayindicatepneumothorax.However,absentbreathsoundsareconsidereda
hallmarksignofpneumothorax.
b.Pleuraleffusionscausefluidtoaccumulateinthepleuralspace.Thiscreatesaphysicalbarriertotransmissionof
breathsounds.
c.COPDpatientshavediminishedbreathsoundsduetoairtrappingandhyperinflatedlungs.
d.Foreignbodyairwayobstructionandmucouspluggingmayalsoreduceairflowcausingdiminishedbreathsounds
overtheobstructedlung.
e.Obesepatientsmayhavediminishedbreathsoundsduetopoorsoundtransmission.
f.Overlysedatedpatientsmayhavediminishedbreathsoundsduetoshalloworslowbreathing.

Adventitiousbreathsounds
Adventitiousbreathsoundsareabnormaladdedorextrasoundssuperimposedovernormalbreathsoundsduring
auscultationofthelungs.
1.Wheezeisacontinuoushighpitchedsound.
2.AsthmaIfduetoasthmawheezingshouldbebilateral.Thereisnosuchthingasunilateralasthma.Recommend
aerosolizedalbuterolifwheezingisbilateralandasthmaissuspected.Ifbreathsoundschangefromwheezingto
markedlydiminishedafterreceivingaerosolizedalbuterol,thepatientisgettingworseandneedsmoreaggressive
therapy.Recommendacontinuousnebulizerwithahigherdoseofalbuterol.
3.ForeignbodyairwayobstructionUnilateralwheezingishighlysuspiciousforforeignbodyairwayobstruction,
particularlyinachild.Unilateralwheezingcausedbyforeignbodyaspirationcanbetreatedwithrigidbronchoscopy.Of
course,ifthepatientshowssignsofhypoxemiayoumustrememberyourprioritiesandgiveoxygenfirst.
4.Finecracklesaremostoftenduetopulmonaryedemaandatelectasis.Finecracklescannotbeclearedwith
suctioning.ForpatientswithfinecracklesduetoCHF/pulmonaryedemarecommend:oxygen,diureticssuchas
FurosemideorLasix,andpositiveinotropicagents.
5.Coarsecracklesoccurwhensecretionsmoveintheairwaysduetopneumoniaorbronchitis.Coarsecracklesdueto
secretionsareheardonbothinhalationandexhalation.Recommendcoughingand/orsuctioningforpatientswith
coarsecrackles.
6.Stridorisaserioussignofairwayobstruction.Thiscanbeduetoforeignbodyairwayobstruction,postextubation
edema,orcroup.Stridorisaudiblemostlyduringinspiration.Treatmentofstridordependsonitsseverity:
a.Mild/moderatestridorIfstridorisonlymoderateandthepatientisstable,youwillhavetimetotreatitwithout
intubation.Recommendoxygen,racemicepinephrine,rigidbronchoscopyifforeignbodyairwayobstruction.
b.SeverestridorSeverestridoroftenoccursinpatientswithepiglottitis.Severestridorcompromisesbothventilation
9/24/2017 5 Patient Assessment Skills To Crush The TMC-RRT Exam - Respiratory Therapy Programs

andoxygenationofthepatient.Severestridorrequiresimmediateintervention.Therefore,recommendintubationfora
patientwithseverestridor.

AuscultationOfTheVoice
Auscultationofvoicesoundshelpsdetectlungconsolidationssuchaspneumonia.Voicesoundschangeastheymove
overconsolidatedlungs.Anychangeinvoicesoundorintensitywhileauscultatingmayindicatepneumonia.
1.Egophonywhileauscultatingeachlungfield,thepatientisinstructedtosaytheletterE.Innormallungs,without
anydiseaseprocess,theEwillsoundlikeanE.However,whenthereisaconsolidation,suchaswithpneumonia,the
EwillsoundlikeanA.
2.Bronchophonywhileauscultatingeachlungfield,thepatientisinstructedtorecitethewordninetynine.Ifan
increasedintensityandclarityisnoted,thepatientmayhaveaconsolidationsuchaspneumonia.
3.Whisperedpectoriloquywhileauscultatingeachlungfieldthepatientisinstructedtowhisperninetynine.If
thesewordsareclearitissuggestiveofaconsolidationsuchaspneumonia.

Inspection
Thoracicconfiguration

NormalconfigurationThechestdiameterfromfronttobackshouldbelessthanthesidetosidediameter.Inmore
technicalterms,theAnteriorposteriordiametershouldbelessthanthetransversediameter.

Abnormalthoracicconfigurations:
1.Atrophybothneuromusculardiseaseandprolongedmechanicalventilationcancausewastingawayofthe
accessorymuscles.Thesepatientsoftenhavetroubleclearingairwaysecretions.Thetherapistcanrecommendthe
patientuseaninexsufflationdevicetoassistthepatientwithairwaysecretionclearance.
2.HypertrophypatientswithsevereCOPDrelyonthesemusclestobreatheevenwhileatrest.Thisisduetothe
lossofelasticrecoilintheirlungsanddisplacementofthediaphragmduetoairtrapping.Asaresult,theaccessory
musclesofrespirationbecomeenlarged.
3.BarrelchestPatientswithsevereCOPDmayhaveincreasedAPdiameterduetohypertrophyofaccessory
musclesandhyperinflation(airtrapping).Thinkoftheterminologybarrelchest,airtrapping,increasedAPdiameter,
andhyperinflationasallbeingsynonymouswitheachotherandalsoassociatedwithCOPD.

Workofbreathing
NormalWorkofBreathing
Patientswithanormalworkofbreathingwillhaveanormalrespiratoryrateandrhythm.Theabdomenwillmovegently
outwardwithinhalationandinwardwithexhalation.Theaccessorymusclesofrespirationwillbeonlyslightlyactive.

LaboredorIncreasedWorkofBreathing
Signsmayincludeincreasedaccessorymuscleuse,retractions,trachealtugging,nasalflaring,orthepatients
subjectivecomplaintofshortnessofbreathand/ordyspnea.
1.Accessorymuscleuseisassociatedwithincreasedairwayresistanceandmusclefatigue.Accessorymuscles
includethescalene,sternocleidomastoid,pectoralismajor,trapezius,andinternalintercostal.
2.Retractionsappearasaninwarddepressionoftheskinaroundthechestwallcausedbyforcefulinspiration.
Retractionscanbeintercostal,supraclavicular,andsternal.Retractionsareasignofsevereairwayobstructionand/or
respiratorydistress.