Physical Exam: Client & Family Education

I. Adult Learning Theory

• Self-directed
• Reservoir of experience
• Adults prefer mutual planning/goal setting
• Internally motivated
• Established orientation to learning
• Educator is facilitator of learning
• Experiential rather than didactic
• Must be immediately applicable to life

II. Teaching/Learning Process

• Assessment
• Identification of learning needs
• Outcome (goal) setting
• Educational offerings
• Evaluation of outcomes

III. Learning Styles

• Vary with individuals
• Learners can be visual, auditory, or tactile (kinesthetic)

IV. Teaching Strategies

• Demonstration/ return demonstration
• Programmed instruction
• Role playing
• Simulation
• Case study analysis
• May be individualized or in groups
• May be computerized
• May be media-based or print

V. Legal Implications

• American Hospital Association issued the Patient Bill of Rights in 1973 that guaranteed clients the right to information necessary to give informed consent before treatment begins
• Individualized teaching must be documented in client's chart
• Alterations for geriatric clients - (i) make sure client has glasses or hearing aid (ii) face the client and use a lower pitched voice (iii) supplement oral presentation with print materials (iv) use large print (v) provide good lighting (vi) some clients have a hard time seeing color; use black on white or yellow paper (vii) keep sessions short and work with survival-level information initially (viii) repeat often for clients prone to memory loss (ix) break down learning into small steps (x) use specific, step by step directions and have the client redemonstrate them (xi) get frequent feedback regarding client's level of understanding
• Patient Protection and Affordable Care Act (PPACA) - signed into law in 2010. This law includes important new protections for millions of working Americans and their families who have preexisting medical conditions or might suffer discrimination in health coverage based on a factor that relates to an individual's health. PPACA places requirements on employer-sponsored group health plans, insurance companies and health maintenance organizations. PPACA includes changes that:

1. Guaranteed issue and partial community rating will require insurers to offer the same premium to all applicants of the same age and geographical location without regard to most pre-existing conditions (excluding tobacco use).
2. A shared responsibility requirement, commonly called an individual mandate, requires that nearly all persons not covered by Medicaid, Medicare, or other insurance programs purchase and comply with an approved insurance policy or pay a penalty, unless the applicable individual "is a member of a recognized religious sect" exempted by the Internal Revenue Service, or waived in cases of financial hardship.
3. Medicaid eligibility is expanded to include all individuals and families with incomes up to 133% of the poverty level along with a simplified CHIPenrollment process.
4. Health insurance exchanges will commence operation in each state, offering a marketplace where individuals and small businesses can compare policies and premiums, and buy insurance (with a government subsidy if eligible).
5. Low income persons and families above the Medicaid level and up to 400% of the poverty level will receive federal subsidies on a sliding scale if they choose to purchase insurance via an exchange (persons at 150% of the poverty level would be subsidized such that their premium cost would be of 2% of income or $50 a month for a family of 4).
6. Firms employing 50 or more people but not offering health insurance will also pay a shared responsibility requirement if the government has had to subsidize an employee's health care.
7. Very small businesses will be able to get subsidies if they purchase insurance through an exchange.
8. Insurers are prohibited from establishing annual spending caps. Insurance companies will also be required to spend a certain percent of premium dollars on medical care improvement. If an insurer fails to meet this requirement, it will be required to provide a rebate to the policy holder.
9. Co-payments, co-insurance, and deductibles are to be eliminated for select health care insurance benefits considered to be part of an "essential benefits package" for Level A or Level B preventive care
10. The law will introduce minimum standards for health insurance policies and remove all annual and lifetime coverage caps.
11. Changes are enacted which allow a restructuring of Medicare reimbursement from "fee-for-service" to "bundled payments."
12. Establishment of a national voluntary insurance program for purchasing community living assistance services and support.
13. Additional support is provided for medical research and the National Institutes of Health.

• The first ever federal privacy standards to protect patient's medical records and other health information provided to health plans, doctors, hospitals and other health care providers took on April 12, 2003. Developed by the Department of Health and Human Services (HHS), these new standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed
• The new privacy regulations ensure protection for patients by limiting the ways that health plans, pharmacies, hospitals and other covered entities can use protected medical records and to other individually identifiable health information, whether it is on paper, in computers or communicated orally. Key provisions of these new standards include:

1. access to medical records
2. notice of privacy practices
3. limits use of personal medical information
4. prohibition on marketing
5. stronger state laws
6. confidential communications
7. complaints

POINTS TO REMEMBER:

• Teaching-learning process mirrors the nursing process
• Select teaching strategies that are compatible with the client's learning style, age, culture, level of education
• Client teaching should be multi-sensory
• Always confirm the client's understanding of the information presented
• Teaching must be geared to the level of the learner
• Repeat key information and summarize main points at intervals
• Explain medical terminology in lay terms
• Determine the client's learning style and gear teaching methods to using that style
• Sequence information the way the client will use it
• Be concrete and use the simplest words and the shortest sentences when teaching low literacy clients, or any client under stress

Physical Exam: Neurological System

I. History
II. Mental Status

• Mini-Mental Status Exam (MMSE) - commonly used assessment tool to quantify a person's cognitive ability. It assesses orientation, registration, attention and calculation and language. Scoring is from 0 to 30, with 30 indicating intact cognition.

III. Emotional Status

• Normal findings: affect matches speech

IV. Cranial Nerve Function

CRANIAL NERVE FUNCTION

CN I. Olfactory Nerve

• can identify variety of smells
• deviation: inability to identify aroma

CN II. Optic Nerve

• has visual acuity and full visual fields
• fundoscopic exam reveals no pathology
• deviation: inability to identify full visual fields - total or partial blindness of one or both eyes

CN III (Oculomotor), CN IV (Trochlear), CN VI (Abducens)

• follows up to six cardinal positions of gaze
• pupils are unremarkable
• exhibits no nystagmus and no ptosis
• deviation: one or both eyes will deviate from its normal position

CN V. Trigeminal Nerve

• clenches teeth with firm bilateral pressure
• has no lateral jaw deviation with mouth open 
• feels a cotton wisp touched to forehead, cheek and chin
• differentiates sharp and dull sensations on the face
• Corneal Reflex: blinks when cotton is touched to each cornea
• deviation: absent or one-sided blinking of eyelids

CN VII. Facial Nerve

• has facial symmetry with an without a smile
• can raise the eyebrows symmetrically and grimace
• can shut eyes tightly
• can identify sweet, sour, salt or bitter on the anterior tongue
• deviation: irregular and unequal facial movements
• deviation: inability to taste or identify taste
• deviation: inability to taste or identify salt, sweet, sour or bitter substances on the anterior two-thirds of the tongue
• deviation: inability to smile symmetrically

CN VIII. Acoustic Nerve

• can hear a whisper at 1-2 feet
• can hear a watch tick at 1-2 feet
• does not lateralize the Weber test
• can hear AC (air conduction) better than BC (bone conduction) in the Rinne's Test
• deviation: inability to hear a spoken word

CN IX (Glossopharyngeal), CN X (Vagus)

• swallows and speaks without hoarseness
• palate and uvula rise symmetrically when patient says "ah"
• bilateral gag reflex
• can identify taste on the posterior tongue
• deviation: unequal or absent rise of uvula and soft palate as client says "ah"
• deviation: absent gag reflex
• deviation: inability to taste or identify taste on the posterior tongue

CN XI. Spinal Accessory Nerve

• resists head turning
• can shrug against resistance
• deviation: weak or absent shoulder and neck movement

CN XII. Hypoglossal Nerve

• can stick tongue out and move it from side to side
• can push tongue strongly against resistance
• deviation: tongue deviates to side

PhotoCredit: dejana.nl

V. Level of Consciousness (LOC): Normal Findings

• alert
• responds appropriately to visual, auditory, tactile and painful stimuli
• able to carry out simple commands
• Glasgow Coma Scale
• alterations in LOC

ALTERATIONS IN LEVEL OF CONSCIOUSNESS

Alert

• Awake and aware of person, place, time and situation
• Responds appropriately and to verbal stimuli

Lethargic

• Sleeps but easily aroused
• Speaks and responds slowly and appropriately

Obtunded

• Difficult to arouse
• Returns to sleep quickly; may respond inappropriately

Stuporous

• Aroused only through pain
• No verbal response

Semicomatose

• Responds only through pain
• Gag and blink reflexes intact

Comatose

• No response to pain
• No reflexes or muscle tone

Note: Dying clients will proceed through these levels in this above-listed sequence.

VI. Sensory Function: Normal findings

• Visual - recognize objects
• Auditory - identifies sounds
• Tactile - identifies objects though blind touch; perceives pain, hot and cold and vibration; two-point discrimination
• Olfactory - identifies familiar smells

ASSESSMENT OF SENSORY NERVE FUNCTION (Done with Client's Eyes Closed)

Superficial Pain

• Prick with sterile needle
• Have client identify whether sharp or dull

Temperature

• Two test tubes - one filled with hot water, the other with cold water
• Client identifies hot versus cold sensation and where it is felt

Light Touch

• Cotton ball; apply light wisp of cotton to different surface points
• Client identifies when touched

Vibration

• Low pitched tuning fork
• Apply to distal interphalangeal joint of finger then toe
• Client identifies when vibration stops

Position

• Grasp client's finger or great toe, holding by its sides
• Client identifies if moving up or down

Two-Point Discrimination

• Two safety pins
• Apply lightly and simultaneously to two different places on skin's surface
• Usually start with finger pads
• Find minimal distance at which client can discriminate one from two points, normally <5mm on finger pads
• Client identifies when can discriminate one from two points

Stereognosis

• Use coin or paper clip or any familiar object with client's eyes closed
• Client identifies object to identify by touch and manipulation

Graphesthesia (Number Identification)

• Number is traced on the client's palm by a blunt object
• Client identifies number

Extinction

• Corresponding areas on both sides of body are simultaneously stimulated
• Client identifies where touched

VII. Cerebellar Function: Position and Balance

CEREBELLAR FUNCTION

• Romberg Test - tests position sense, note client's ability to stand upright when standing with feet together and eyes closed for 20-30 seconds
• Hop in Place - maintains balance while hopping on one foot
• Knee Bends - maintains balance while bending at knees
• Tandem Walking - walks heel to toe in straight line
• Rapid Skills

1. pronates and supinates hands rapidly with equal timing and purposeful movements
2. touches alternate finger to nose rhythmically with eyes open and closed
3. moves fingers alternately from nose to examiner's finger in coordinated fashion
4. runs contralateral heel down shin with bilateral coordination

• One Foot Balance

1. maintains balance on one foot for at least five seconds
2. bilateral response with eyes open and closed

VIII. Speech and Language: Normal Findings

• Smooth flowing speech
• Able to formulate words without difficulty
• Varied inflection
• Able to write letters and numbers to dictation
• Vocabulary appropriate to educational level

IX. Intellectual: Normal Findings

• Memory - immediate recall and remote recall
• Oriented to person, place and time
• Able to abstract
• Demonstrates consistent insight and perception of self

X. Reflexes: Assessmend and Grading

TESTS FOR REFLEXES

I. Deep tendon reflexes with selected site stimulus

• Biceps reflex (C5, C6) - flexion of arm at elbow
• Triceps reflex (C6, C7) - extension of arm at elbow and contraction of triceps muscles
• Brachioradialis (supinator) reflex (C5, C6) - flexion at elbow and pronation of forearm
• Quadriceps (knee-jerk or patellar) reflex (L2, L3, L4) - extension of leg at knee and contraction of quadriceps
• Achilles (ankle-jerk) reflex (S1, S2)

II. Superficial reflexes

• Pharyngeal reflex (CN IX, CN X)
• Upper abdominal reflex (T8, T9, T10) - upward movement of umbilicus toward stimulus above umbilicus
• Lower abdominal reflex (T10, T11, T12) - downward movement of umbilicus toward stimulus below umbilicus
• Cremasteric reflex (T12, L1) - elevation of ipsilateral testicle (the side stimulated)
• Gluteal reflex (L4-S3) - contraction of anal sphincter with gloved finger insertion

III. Pathologic reflexes in adults - documented as "positive for ___"

• Babinski reflex (plantar) (L4-S2) - stroking lateral sole of foot causes dorsiflexion of great toe with fanning of other toes (normal expectation in children up to age 18 months on the average)
• Chaddock reflex (L4-S2) - stroking below lateral malleolus causes dorsiflexion of great toe with fanning of other toes
• Ankle clonus - brisk dorsiflexion of foot with knee flexed causes up and down movement of foot; found in severe preeclampsia
• Oppenheim - stroking tibial surface causes great toe fans out
• Gordon - squeezing calf muscle; great toe fans out
• Hoffman - flicking middle finger down; flexion of the tumb

IV. Common Expected Reflexes: normal for all ages

• Gag
• Corneal

REFLEX GRADING

0     -     No response

1+   -     Sluggish or diminished response

2+   -     Normal

3+   -     Brisker than normal

4+   -     Hyperactive and very brisk (may be associated with spinal cord disorder)

XI. Geriatric Alterations in Neuro Status

• Longer response time to sensory stimulation
• May resist new ideas or change
• Thought patterns may become more concrete
• Kinesthesia diminishes - the ability to perceive extent, direction or weight of movement
• Superficial and deep reflexes may be diminished or absent

POINTS TO REMEMBER:

• Glasgow Coma Score

1. not valid in patients who have used alcohol or other mind-altering drugs
2. possibly not valid in patients who are hypoglycemic, in shock, or hypothermic (below 34 degrees Celsius)

• Reflexes are normally less brisk or even absent in older clients
• Reflex response diminishes in the lower extremities before the upper extremities are affected
• Absent reflexes may indicate neuropathy or lower motor neuron disorder
• Hyperactive reflexes suggest an upper neuron disorder

Physical Exam: Musculoskeletal System

I. History: Participation in sports, risk factors for osteoporosis, impact of current problem on activities of daily living


II. Inspection

• Gait: Normal findings - client walks with arms swinging freely at sides; coordinated and smooth; rhythmic with push off and swing through
• Posture and Balance: Normal findings

1. upright stance with parallel alignment  of hips and shoulders
2. feet aligned; toes pointing straight ahead
3. convex curve to thoracic spine
4. concave curve to lumbar spine
5. can stand still without swaying or tilting

• Extremities: Normal findings - bilateral symmetry in length, circumference. alignment, position and number of skin folds

III. Palpation

• All muscles, bones, joints
• Normal findings - muscles firm, non-tender

IV. Range of Motion: Normal findings - able to move joints through required range of motion

• Abduction - lateral movement of the limbs away from the median plane of the body, or lateral bending of the head or trunk
• Adduction - movement of a limb or eye toward the median plane of the body or, in the case of digits, toward the axial line of a limb
• Dorsiflexion - movement of a part at a joint to bend the part toward the dorsum, or posterior aspect of the body
• Eversion - turning outward
• Extension - a movement that brings the members of a limb into or towards a straight position
• Flexion - the act of bending or condition of being bent in contrast to extension
• Hyperextension - extreme or abnormal extension
• Inversion - a turning inside out of an organ (e.g. the uterus)
• Plantar flexion - extension of the foot so that the forepart is depressed with respect to the position of the ankle
• Pronation - the act of lying prone or face downward
• Supination - the condition of being on the back of having the palm of the hand facing upward or the foot turned inward and upward

V. Muscle Strength and Symmetry: Normal findings - arm on dominant side generally stronger

VI. Alterations

• Kyphosis - exagerration or angulation of the normal posterior curve of the spine, giving rise to the condition commonly known as humpback. hunchback or Pott's curvature
• Lordosis - abnormal anterior convexity  of the lumbar spine
• Scoliosis - lateral curvature of the spine
• Pain

VII. Geriatric Alterations

• Stance less upright with head and neck forward
• Lumbar curvature less pronounced
• Height decreased
• Gait slower to initiate and stop
• Less knee and ankle lifts
• Steps may be shorter and more rapid
• May need to hold unto furniture as age increases
• Muscles atrophy with disuse
• Weaker grip
• Active range of motion may be slower and limited in one or more joints
• Joints appear larger than surrounding tissue; may be stiff

POINT TO REMEMBER:

• Older adults walk with smaller steps and need a wider base of support

Physical Exam: Male Reproductive System

I. History: Sexual history, sexually transmitted disease, contraception, surgery, associated urinary problems

• External genitalia
• Hair distribution: varies; hair extends from base of penis over symphysis pubis; coarse and curly
• Penis shaft, corona, prepuce, glans
• Urethral meatus is slit like opening positioned on ventral surface, millimeters from tip of glans; opening should be glistening and pink
• Scrotum:

1. skin more darkly pigmented; more wrinkled; usually loose
2. symmetry - left testicle is lower than right
3. size - changes with temperature

• Inguinal canal: no finding - no bulging

II. Palpation

•  Penis:

1. foreskin should retract easily
2. small amount of thick white secretion between glans and foreskin is normal
3. testicle - ovoid; ranges from 2-4 cm in diameter, smooth and rubbery; nontender

• Inguinal canal: Normal finding - inguinal lymph nodes not palpable

III. Geriatric Alterations

• Increased bogginess of prostrate
• Testes softer

IV. Rectum and Anus

• Inspection of perianal areas

1. skin - smooth and uninterrupted
2. anal tissues - normally moist and hairless

• Digital palpation:

1. Anal sphincter - note tone
2. Rectal walls - smooth and even
3. Prostrate gland = Palpate through anterior rectal wall; Small walnut-sized, heart shaped structure; Ranges from 2.5 to 4 cm in diameter; Normal findings - firm, protrudes <1 cm into rectum

• Alterations:

1. fissures
2. fistulas
3. polyps
4. pain
5. hemorrhoids

PhotoCredit: hemorrhoidtreatmentanswers.com

Physical Exam: Female Reproductive System

I. History: sexually transmitted disease, menstrual history, obstetrical history, contraception

II. Inspection

• External genitalia: Normal findings

1. hair distribution: variable; usually inverted triangle starting at symphysis pubis
2. skin of perineum smooth, clean, slightly darker than other skin
3. labia majora - may be closed or gaping
4. clitoris - about 2 cm in length and 0.5 cm in width
5. urethral orifice - intact, pink without irritation
6. vaginal orifice - ranges from thin, vertical slit to larger orifice with moist tissue
7. anus - moist and hairless - skin more darkly pigmented

• Internal genitalia:

1. Cervix - normal findings: pink; midline; usually about 2 to 3 cm in diameter; smooth, firm, rounded or oval; odorless, creamy or clear secretions
2. papanicolau (Pap) smear
3. vagina - pink throughout; clear or cloudy, odorless secretions; about 10 to 15 cm in length

III. Palpation

• Ovaries may or may not be palpable; firm, slightly tender, oval, mobile; about 4 cm in diameter
• Uterus - mobile; rounded; palpable at level of pelvis
• Skene's glands and Bartholin's gland - normal findings: nontender, no discharge

IV. Geriatric Alterations

• Labial folds flatten
• Skin paler, shiny
• Meatus usually more posterior
• Cervix decreases in size; may appear paler
• Scanty cervical discharge
• Vagina shortens with age
• Decreased vaginal secretions
• Uterus diminishes in size; may not be palpable
• Ovaries atrophy with age

Physical Exam: Abdomen

I. History

• Pain, bowel habits, dietary problems, weight change, difficulty swallowing, flatulence, belching, heartburn, nausea, vomiting, cramping
• Changes in micturition including: change in amount and color of urine, irritation of lower urinary tract, urinary incontinence, urinary tract pain

II. Inspection

• Landmarks: 

1. Xiphoid process - marks upper boundary of abdomen 
2. Symphysis pubis - marks lower boundary 
3. Abdomen divided into four quadrants - RUQ, RLQ, LUQ, LLQ

• Normal findings: 

1. skin texture and color should be consistent with rest of body
2. striae may be present
3. umbilicus is normally flat or concave midway between xiphoid and symphysis pubis
4. abdomen may be flat, concave or convex; all three are normal if there is symmetry
5. you may not peristalsis movement or aortic pulse
6. voiding - steady, straight stream with no pain or post void dribble

III. Percussion

• Normal findings: Tympany over stomach and intestines; dullness over liver, spleen, pancreas, kidneys and distended (>150 cc) bladder
• Liver border:

1. usually noted in the 5th, 6th or 7th intercostal space
2. distance between upper and lower borders should range between 6 to 12 cm at right midclavicular line

• Spleen:

1. Left posterior midaxillary line - dullness at 6th to 10th rib
2. Left intercostal space in anterior axillary line - tympany

IV. Palpation

• Normal findings: soft with no palpable masses, no tenderness or rigidity
• Bladder noted as a bulge in abdomen when filled with more than 500cc of urine
• Deep palpation may produce tenderness - liver, kidneys, spleen inguinal nodes generally not palpable

V. Auscultation

• Bowel motility: normal findings - audible in all quadrants
• Vascular sounds: normal findings

1. no vascular sounds over aorta or femoral arteries
2. renal artery bruits can be heard

VI. Alterations

• Distention
• Ascites
• Paralytic ileus
• Borborygmus
• Guarding (muscle contract)
• Tenderness
• Pain

VII. Geriatric Alterations

• Increased fat deposits over abdominal area
• Muscle tone more lax

POINTS TO REMEMBER:

• Auscultation should be performed before palpation to prevent distortion of bowel sounds
• Tightening of abdominal muscles hinders accuracy of palpation and auscultation
• Warm hands before touching client's abdomen
• Men breathe abdominally; women breathe costally
• Auscultate all four quadrants for bowel sounds
• Auscultate abdomen between meals

Physical Exam: Breasts

I. Inspection (Performed with client in lying, sitting or standing position)

• Size: Vary from convex to pendulous
• Symmetry: (The breast in the same side as your dominant hand is commonly larger than the other)
• Skin: Color, venous pattern, possibly a few hairs around areola
• Alterations:

1. retractions
2. dimpling
3. lesions
4. edema
5. inflammation

• Alterations with Pregnancy and Lactation:

1. enlargement of breasts
2. soreness of nipples during lactation
3. possible striae

• Nipple and areola:

1. size
2. color - ranges from pink to brown
3. shape - areola round or oval; nipples everted
4. symmetry - normally symmetrical
5. direction - normally nipples point in same direction
6. alterations - discharge; inverted nipples; bleeding

II.Palpation - Breast

• Lymph nodes: Normal findings - not palpable
• Breast tissue

Client should be in supine position with hand placed behind the neck.

• Methods of Examining Breast:

1. Clockwise or counterclockwise circling breast from nipple outward
2. Back and forth with fingers moving up and down each breast

• Consistency:

1. varies widely from person to person
2. Normal findings - dense, firm, and elastic

• Alterations: fibrocystic disease of the breast
• Geriatric alterations:

1. relaxed breasts 
2. may appear elongated or pendulous
3. decrease in glandular tissue

POINTS TO REMEMBER:

• Breast tissue shrinks with menopause
• Teach client breast self examination:

Physical Exam: Lungs

I. History: smoking, infections, pain, discomfort, dyspnea, activity intolerance, fever
II. Inspection


General Appearance: Respiration

• Breathing should be quiet and easy
• Respiration involves ventilation, diffusion, and perfusion of gases
• Factors influencing respirations: exercise, pain, anxiety, stress, anemia, posture, drugs (narcotics, amphetamine)
• Normal Rates of Respiration: Newborn - 35 to 40 breaths/minute; Infant - 30 to 50 breaths/minute; Toddler - 25 to 35 breaths/minute; Schoolage - 20 to 30 breaths/minute; Adolescent - 14 to 20 breaths/minute; Adult - 12 to 20 breaths/minute
• Depth: deep, normal, shallow
• Rhythm: regular, irregular; Normal Finding: regular
• Skin color
• Chest wall configuration: Normal Findings - symmetrical with bilateral muscle development; A-P Transverse Ration = 1-5:2-7

III. Palpation

• Feel for abnormalities such as masses, lesions, scars, swelling, crepitus, asymmetry
• Crepitus indicates air in subcutaneous space (in thoracic area, usually due to pneuomothorax)
• Vocal fremitus: Vibration felt when patient speaks; Increased over areas of consolidation

IV. Percussion

• Normal findings: resonance heard throughout lung fields

V. Auscultation

• Normal findings: quiet breathing throughout all lung fields
• Whispered pectoriloquy:

1. Client whispers "One, two, three" 
2. Over normal areas of the lung, only faint sounds are heard
3. Over consolidated areas, the words are more distinct

• Egophony:

1. Client says "E"
2. Over consolidated areas, the sound is a nasal "A"

VI. Alterations in Lung Function

• Cough
• Expectoration
• Dyspnea
• Bradypnea
• Tachypnea
• Hyperpnea
• Apnea
• Cheyne-Stoke respiration
• Kussmaul's breathing
• Biot's breathing
• Grunting
• Retractions
• Hemoptysis
• Pain
• Accessory muscle use
• Cyanosis
• Adventitious sounds
• Pursed-lip breathing:

1. Prolonged exhalation
2. Breathing out through puckered lips

• Pleural friction rub:

1. Grating sound produced by inflamed pleura rubbing together
2. Usually heard loudest over lower lateral anterior chest at end of inspiration

VII. Pediatric Differences

• Smaller, shorter, more pliable airways
• Underdeveloped supporting cartilage
• Above two factors increase the risk of obstruction due to mucus, edema or foreign body
• Flexible larynx more susceptible to spasm
• Immature immune system
• Incomplete myelinization
• Increased basal metabolic rate
• Decreased ability to mobilize secretions
• Less forceful cough

POINTS TO REMEMBER:

• Anemic patients may never become cyanotic
• Polycythemic patients may become cyanotic, even when oxygenation is normal
• Cough results from stimulation of irritant receptors, with implications of either acute or chronic etiology
• Cyanosis indicates decreased available oxygen. Etiology can be either peripheral or central in origin
• Wheezes indicates narrowing/inflammatory process of lower airways
• Stridor harsh sound produced near larynx by vibration of structures in upper airway. Classic "barky cough"
• Crackles or rales adventitious sounds, usually on inspiration and indicating inflammation