Advanced Health Assessment and Diagnostic Reasoning Rhoads, Jacquel
Petersen, Sandra Wiggins
Study online at https://quizlet.com/_b54tcr
1. Physical Examina- 1. Place the patient in an upright position. If possible, do so without supporting
tion Inspection the patient, so you can see the effort it takes to maintain that position and inspect
breathing patterns. Remove clothing to better visualize the chest area.
2. Make sure the room and stethoscope are warm and a gooseneck lamp is available
to highlight chest movement.
3. Position the patient so that the gooseneck lamp can be positioned to shine at
different angles.
4. If the patient is unable to leave the bed due to his or her condition, raise and
lower the bed as needed. Also, ensure room for maneuvering around the bed.
5. Inspect the general appearance.
a. Inspect the skin, noting whether pallor is present. Skin color can tell the exam-
iner if circulation is adequate. Pallor or cyanosis can indicate low oxygenation or
hypoxemia.
b. Inspect the face and mouth. •Observe the lips for cyanosis and pursing. •Smell
the patient's breath. •Observe the nares for flaring. •Pursing of the lips is associated
with increased expiratory effort. As cyanosis is a latent sign of hypoxia, when
cyanosis is visible, the
hypoxic condition has progressed to a dangerous level. •Infection present in the
respiratory system may make the patient's breath malodorous. Metabolic condi-
tions, such as diabetes, may give the patient's breath a fruity odor. •Nasal flaring
during inspiration is a common sign of air hunger, particularly when the alveoli are
considerably involved.
c. Observe the fingers for clubbing. Clubbing of fingers is commonly noted in
patients with chronic fibrotic changes in the lungs. Other chronic problems involving
the lungs, such as asthma and emphysema, are not associated with clubbing.
6. Inspect the thorax.
a. Determine the shape and symmetry of the thorax (anterior and posterior).Lo-
cation of the landmarks allows for proper documentation. The rib cage should be
obvious, with the clavicles apparent superiorly, and the sternum flat. The chest
is not symmetrical, but each side can be used to compare with the other. The
1/8
, Advanced Health Assessment and Diagnostic Reasoning Rhoads, Jacquel
Petersen, Sandra Wiggins
Study online at https://quizlet.com/_b54tcr
anteroposterior (AP) diameter of the chest is normally less than the transverse
diameter, often by as much as half. Barrel chest associated with chronic asthma,
emphysema, or cystic fibrosis results from the patient's long-term compromised
respiration. The ribs are horizontal, the vertebral spine will appear kyphotic, and
the sternal angle more prominent. The trachea may be posteriorly displaced as a
result of the compromised breathing patterns. Pectus carinatum (pigeon chest),
where the sternum protrudes, and pectus excavatum (funnel chest), where the
lower sternum above the xiphoid process is indented, may be clues to respiratory
or cardiac disorder. Also note any deviation of the spine. It may be deviated either
posteriorly (kyphosis) or laterally (scoliosis)
b.Note whether there are supernumerary nipples. Supernumerary nipples (SNs)
are a congenital abnormality, particularly found in Caucasian patients. They are
defined as the presence of nipples and/ or related tissue in addition to the two
nipples normally appearing on the anterior chest wall. SNs are located along the
embryonic milk line. (The embryonic milk line extends bilaterally from a point
slightly beyond the axilla on the arm, down the chest and the abdomen toward the
groin, and ends at the proximal inner side of the thigh.) SNs can appear complete
with breast tissue and ducts and are then referred to as polymastia, or they can
appear partially with some breast tissue involved.
c. Look for any superficial venous patterns over the chest Venous patterns over the
chest may be a sign of heart disorders, vascular obstruction, or disease. They are
caused by thoracic pressure.
d. Determine the presence of fat or prominence of bony areas. Underlying fat and
relative prominence of the ribs provide information as to nutritional state.
e. Establish the respiratory rate. To avoid an anticipatory response that could
mislead you, do not let the patient know that you are counting respirations. Count
respirations while palpating the pulse. The respiratory rate should be 12- 20
respirations per minute; the ratio of respirations to heart rate is approximately
1: 4. Respiratory rates higher than 20 respirations per minute need evaluation to
determine respiratory distress, obstruction, anxiety, and pain. Respiratory rates can
vary when the patient is awake or asleep. When counting respiratory rate, make
2/8
Petersen, Sandra Wiggins
Study online at https://quizlet.com/_b54tcr
1. Physical Examina- 1. Place the patient in an upright position. If possible, do so without supporting
tion Inspection the patient, so you can see the effort it takes to maintain that position and inspect
breathing patterns. Remove clothing to better visualize the chest area.
2. Make sure the room and stethoscope are warm and a gooseneck lamp is available
to highlight chest movement.
3. Position the patient so that the gooseneck lamp can be positioned to shine at
different angles.
4. If the patient is unable to leave the bed due to his or her condition, raise and
lower the bed as needed. Also, ensure room for maneuvering around the bed.
5. Inspect the general appearance.
a. Inspect the skin, noting whether pallor is present. Skin color can tell the exam-
iner if circulation is adequate. Pallor or cyanosis can indicate low oxygenation or
hypoxemia.
b. Inspect the face and mouth. •Observe the lips for cyanosis and pursing. •Smell
the patient's breath. •Observe the nares for flaring. •Pursing of the lips is associated
with increased expiratory effort. As cyanosis is a latent sign of hypoxia, when
cyanosis is visible, the
hypoxic condition has progressed to a dangerous level. •Infection present in the
respiratory system may make the patient's breath malodorous. Metabolic condi-
tions, such as diabetes, may give the patient's breath a fruity odor. •Nasal flaring
during inspiration is a common sign of air hunger, particularly when the alveoli are
considerably involved.
c. Observe the fingers for clubbing. Clubbing of fingers is commonly noted in
patients with chronic fibrotic changes in the lungs. Other chronic problems involving
the lungs, such as asthma and emphysema, are not associated with clubbing.
6. Inspect the thorax.
a. Determine the shape and symmetry of the thorax (anterior and posterior).Lo-
cation of the landmarks allows for proper documentation. The rib cage should be
obvious, with the clavicles apparent superiorly, and the sternum flat. The chest
is not symmetrical, but each side can be used to compare with the other. The
1/8
, Advanced Health Assessment and Diagnostic Reasoning Rhoads, Jacquel
Petersen, Sandra Wiggins
Study online at https://quizlet.com/_b54tcr
anteroposterior (AP) diameter of the chest is normally less than the transverse
diameter, often by as much as half. Barrel chest associated with chronic asthma,
emphysema, or cystic fibrosis results from the patient's long-term compromised
respiration. The ribs are horizontal, the vertebral spine will appear kyphotic, and
the sternal angle more prominent. The trachea may be posteriorly displaced as a
result of the compromised breathing patterns. Pectus carinatum (pigeon chest),
where the sternum protrudes, and pectus excavatum (funnel chest), where the
lower sternum above the xiphoid process is indented, may be clues to respiratory
or cardiac disorder. Also note any deviation of the spine. It may be deviated either
posteriorly (kyphosis) or laterally (scoliosis)
b.Note whether there are supernumerary nipples. Supernumerary nipples (SNs)
are a congenital abnormality, particularly found in Caucasian patients. They are
defined as the presence of nipples and/ or related tissue in addition to the two
nipples normally appearing on the anterior chest wall. SNs are located along the
embryonic milk line. (The embryonic milk line extends bilaterally from a point
slightly beyond the axilla on the arm, down the chest and the abdomen toward the
groin, and ends at the proximal inner side of the thigh.) SNs can appear complete
with breast tissue and ducts and are then referred to as polymastia, or they can
appear partially with some breast tissue involved.
c. Look for any superficial venous patterns over the chest Venous patterns over the
chest may be a sign of heart disorders, vascular obstruction, or disease. They are
caused by thoracic pressure.
d. Determine the presence of fat or prominence of bony areas. Underlying fat and
relative prominence of the ribs provide information as to nutritional state.
e. Establish the respiratory rate. To avoid an anticipatory response that could
mislead you, do not let the patient know that you are counting respirations. Count
respirations while palpating the pulse. The respiratory rate should be 12- 20
respirations per minute; the ratio of respirations to heart rate is approximately
1: 4. Respiratory rates higher than 20 respirations per minute need evaluation to
determine respiratory distress, obstruction, anxiety, and pain. Respiratory rates can
vary when the patient is awake or asleep. When counting respiratory rate, make
2/8
