Chapter 7 Body Systems

Chapter 2

The Physical Examination and Its Basis in Physiology

 Body temperature (T)  Pulse (P)  Respiration (R)  Blood pressure (BP)

 Pulse oximetry (SpO2)

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 4 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 5 Four Common Types of Fever

 Intermittent  Remittent  Relapsing  Constant

 Below normal body temperature  Decreased pulse and respiratory rate  Severe shivering (initially)  Patient indicating coldness or presence of chills  Pale or bluish cool, waxy skin  Hypotension

 Decreased urinary output  Lack of muscle coordination  Disorientation  Drowsiness or unresponsiveness  Coma

 Remove wet clothing  Provide dry clothing  Place patient in a warm environment (e.g., slowly increase the room temperature)  Cover patient with a warm blanket or electric heating blanket

 Apply warming pads (increase temperature slowly)  Cover patient’s head with a cap or towel  Supply warm oral or intravenous fluids

 Age  Environment  Time of day  Exercise  Stress  Hormones

 The measurement of body temperature establishes an essential baseline for clinical comparison.  To ensure reliability of a temperature reading:  Select correct equipment  Choose the most appropriate site  Use the correct technique or procedure

 The four most commonly used sites are the:  Mouth  Rectum  Ear (tympanic)  Axilla  Additional sites  Esophagus  Pulmonary artery

 Rectum  Ear (tympanic)  Esophagus  Pulmonary artery

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 14 Table 2-3 Body Temperature Measurements: Summary of Body Temperature Sites, Advantages and Disadvantages, and Equipment Used

 Rate  Rhythm  Strength

0: Absent or no pulse 1+: Weak, thready, easily obliterated with pressure; difficult to feel 2+: Pulse difficult to palpate; may be obliterated by strong pressure 3+: Normal pulse 4+: Bounding, easily palpated, and difficult to obliterate

Time (15 seconds)

Eupnea. Normal range and rhythm; 12 to 20 breaths/min in regular rhythm and of moderate depth for an adult.

Time (15 seconds)

Bradypnea. Regular rhythm of fewer than 12 breaths/min.

Time (15 seconds)

Tachypnea. Regular rhythm of more than 20 breaths/min for an adult.

Time (15 seconds)

Apnea. Absence of breathing that leads to respiratory arrest and death.

Time (15 seconds)

Hypoventilation. Decreased rate and depth, decreasing alveolar

ventilation and leading to an increased PaCO2.

Time (15 seconds)

Hyperventilation. Increased rate and depth, which increases

alveolar ventilation and leads to a decreased PaCO2.

Time (15 seconds)

Cheyne-Stokes. Respirations become faster and deeper, then slower and shallower with a period of apnea.

Time (15 seconds)

Kussmaul’s. Increased rate and depth of breathing. Usually associated with diabetic ketoacidosis as a compensatory mechanism to eliminate excess carbon dioxide.

Volume

Time (15 seconds)

Biot’s. Fast, deep respirations with abrupt pauses.

 The arterial blood pressure is the force exerted by the circulating volume of blood on the walls of the arteries  Systolic blood pressure  Diastolic blood pressure

 Function of:  Blood flow generated by ventricular contraction  Resistance. to blood flow by the vascular system • BP = V × R

 Blood flow is equal to cardiac output  Cardiac output (CO) is equal to:  Volume of blood ejected from the ventricles during each heartbeat (stroke volume [SV]), multiplied by the heart rate. (HR) • CO = SV × HR  Average CO is about 5 L/min

 Hypertension  Blood pressure is chronically above normal  Hypotension  Blood pressure falls below 90/60 mm Hg  Orthostatic hypotension  When blood pressure quickly drops as the individual rises to an upright position or stands

 ↓ Blood pressure during inspiration  ↑ Blood pressure during expiration

 Often considered the fifth vital sign

 Central Nervous System  Apprehension (early)  Restlessness or irritability (early)  Confusion or lethargy (early or late)  Combativeness (late)  Coma (late)

 Respiratory  Tachypnea (early)  Dyspnea on exertion (early)  Dyspnea at rest (late)  Use of accessory muscles (late)  Intercostal retractions (late)  Takes a breath between each word or sentence (late)

 Cardiovascular  Tachycardia (early)  Mild hypertension (early)  Arrhythmias (early or late)  Hypotension (late)  Cyanosis (late)  Skin is cool or clammy (late)

 Other  Diaphoresis (early or late)  Decreased urinary output (early or late)  General fatigue (early or late)

 Inspection  Palpation  Percussion  Auscultation

 Thoracic cage landmarks  Imaginary lines  Lung borders and fissures

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 51 Figure 2-5. Topographic location of lung fissures projected on the anterior chest (A) and posterior chest (B).

 The inspection of the patient is an ongoing observation process that begins with the history and continues throughout the:  Patient interview  Taking of vital signs  Physical examination

 Palpation is the process of touching the patient’s chest to evaluate the:  Symmetry of chest expansion  Position of the trachea  Skin temperature, muscle tone  Areas of tenderness, lumps, and depressions  Tactile and vocal fremitus

 Chest excursion  Tactile and vocal fremitus

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 57 Figure 2-7. Assessment of chest excursion. A, Anterior. B, Posterior. Note the thumbs move apart on inspiration as the volume of the thorax increases.

 Percussion over the chest wall is performed to determine the size, borders, and consistency of air, liquid, or solid material in the underlying lung.

 Dull percussion note  Pleural thickening  Pleural effusion  Atelectasis  Consolidation  Hyperresonant percussion note  Chronic obstructive pulmonary disease  Pneumothorax

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 63 Figure 2-11. A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.

 Causes of minimal diaphragmatic excursion  Alveolar hyperinflation • Examples: severe emphysema, bronchitis, asthma  Lobar collapse of one lung • Lung is pulled up to the affected side, reducing excursion  Neuromuscular disease • Diaphragm may be elevated and immobile

 Auscultation of the chest provides information about the heart, blood vessels, and air flowing in and out of the tracheobronchial tree and alveoli.

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 67 Figure 2-13. Path of systematic auscultation to include all important areas. Note the exact similarity of this pathway to Figure 2-6.

 Bronchial breath sounds  Bronchovesicular breath sounds  Vesicular breath sounds

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 69 Figure 2-14. The location at which bronchovesicular breath sounds (A) and vesicular breath sounds (B) are normally auscultated.

 Bronchial breath sounds  Diminished breath sounds  Crackles and rhonchi  Wheezing  Pleural friction rubs  Stridor  Whispering pectoriloquy

 Described as loud “bronchial-type” sounds  Causes  Alveolar consolidation  Atelectasis

 Causes  Air trapping (e.g., emphysema, bronchitis, asthma)  Flail chest  Pneumothorax  Pleural effusion  Neuromuscular diseases • Guillain-Barré syndrome • Myasthenia gravis

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 75 Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive lung diseases, breath sounds progressively diminish.

 Crackles (rales)—are usually fine or medium crackling wet sounds  Typically heard during inspiration  May or may not change in nature after a strong and vigorous cough  Rhonchi—usually have a coarse, “bubbly” quality  Typically heard during expiration  Often change in nature or disappear after a strong and vigorous cough

 High-pitched and whistling sound  Generally heard during expiration  Most common cause  Bronchospasm

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 78 Figure 2-18. Wheezing and rhonchi often develop during an asthmatic episode because of smooth muscle constriction, wall edema, and mucous accumulation.

 The sound is reminiscent of that made by a creaking shoe  Commonly heard over the area where the patient complains of pain  Cause  Inflamed pleural membranes

 Abnormal audible high-pitched musical sound caused by an obstruction in the trachea or larynx  Generally heard during inspiration  Causes  Acute epiglottis  Laryngotracheobronchitis

 Term used to describe the unusually clear transmission of the whispered voice of a patient as heard through the stethoscope  Causes  Atelectasis  Consolidation

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 83 Figure 2-20. Whispering pectoriloquy. Whispered voice sounds heard over a consolidated lung are often louder and more intelligible compared with those of a normal lung.

 Inspection  Pursed lip breathing  Tripod position; inability to lie flat  Accessory muscle use; intercostal retractions  Splinting  AP diameter  Tachypnea  Kussmaul’s respiration

Modified from Lewis S, Heitkemper MM, Dirksen SR: Medical-surgical nursing: assessment and management of clinical problems, ed 7, vol 1, St Louis, 2007, Mosby.

 Inspection  Cyanosis  Clubbing finger  Peripheral edema  Distended neck veins  Cough  Sputum (amount, color, smell)  Abdominal paradox

Modified from Lewis S, Heitkemper MM, Dirksen SR: Medical-surgical nursing: assessment and management of clinical problems, ed 7, vol 1, St Louis, 2007, Mosby.

 Palpation  Tracheal deviation  Altered tactile fremitus  Altered chest movement  Percussion  Hyperresonance  Dullness

Modified from Lewis S, Heitkemper MM, Dirksen SR: Medical-surgical nursing: assessment and management of clinical problems, ed 7, vol 1, St Louis, 2007, Mosby.

 Auscultation  Fine crackles  Coarse crackles  Rhonchi  Wheezes  Stridor  Absent breath sounds  Pleural friction rub  Whispered pectoriloquy  Bronchophony  Egophony

Modified from Lewis S, Heitkemper MM, Dirksen SR: Medical-surgical nursing: assessment and management of clinical problems, ed 7, vol 1, St Louis, 2007, Mosby.

Composed of:  Tidal volume  About 500 mL (7 to 9 mL/kg)  Ventilatory rate  About 15 breaths/min (range 12 to 18 breaths/min)  Inspiratory-to-expiratory (I:E) ratio  About 1:2

 Scalene  Sternocleidomastoid  Pectoralis major  Scalenes

 Rectus abdominis  External oblique  Internal oblique  Transversus abdominis

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 97 Figure 2-39. Accessory muscles of expiration. Arrows indicate the action of these muscles in enlarging the volume of the lungs.

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 98 Figure 2-40. When the accessory muscles of expiration contract, intrapleural pressure increases, the chest moves outward, and airflow increases.

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 100 Figure 2-41. A, Schematic illustration of alveolar compression of weakened bronchiolar airways during normal expiration in patients with chronic obstructive pulmonary disease (e.g., emphysema). B, Effects of pursed-lip breathing. The weakened bronchiolar airways are kept open by the effects of positive pressure created by pursed lips during expiration.

 Pleuritic chest pain  Sudden, sharp, or stabbing pain  Nonpleuritic chest pain  Constant pain that is located centrally

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 105 Figure 2-43. When the parietal pleura is irritated, the nerve endings in the parietal pleura send pain signals to the brain.

 Associated with:  Pneumonia  Pleural effusion  Pneumothorax  Pulmonary infarction  Lung cancer  Pneumoniosis  Fungal diseases  Tuberculosis

 Associated with:  Myocardial ischemia  Pericardial inflammation  Pulmonary hypertension  Esophagitis  Local trauma or inflammation of the chest cage, muscles, bones, or cartilage

 Altered skin color  Cyanosis  Digital clubbing  Peripheral edema  Distended neck veins

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 111 Figure 2-45. Cyanosis is likely whenever the blood contains at least 5 g of reduced hemoglobin. In the normal individual who has about 15 g of hemoglobin per 100 mL of blood, a PO2 of about 30 mm Hg produces 5 g of reduced hemoglobin. The hemoglobin, however, is still approximately 60% saturated with oxygen.

Figure 2-46. Digital clubbing.

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 113 Figure 2-47. Pitting edema. (From Bloom A, Ireland J: Color atlas of diabetes, ed 2, London, 1992, Mosby-Wolfe.)

Figure 2-48. Distended neck veins (arrows).

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 117 Figure 2-49. The normal lung. ALV, Alveoli; BM, basement membrane; BR, bronchioles; C, cartilage; EP, epithelium; GC, goblet cell; MC, mast cell; PA, pulmonary artery; PN, parasympathetic nerve; RB, respiratory bronchioles; SG, submucosal gland; SM, smooth muscle; TBR, terminal bronchioles.

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 120 Figure 11-1. Chronic bronchitis, one of the most common airway diseases. AWO, Airway obstruction; ESG, enlarged submucosal gland; HALV, hyperinflation of alveoli (distal to airway obstruction); IEP, inflammation of epithelium; MA, mucous accumulation; MP, mucous plug.

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 123 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 124 Nonproductive Cough

 Common causes  Irritation of the airways  Inflammation of the airways  Mucous accumulation  Tumors  Irritation of the pleura

 Assess the following:  Is the cough strong or weak?  Evaluate cough for: • Frequency • Pitch • Loudness  Evaluate sputum for: • Amount • Odor • Color