Section II. PHYSICAL EXAMINATION
a. Physical examination of the nose and sinuses should begin with an overall observation for general deformity or irregularity. Watch the patient breathe through both the mouth and nose. Do the nostrils flare with inspiration? Is the sense of smell intact? The nasal passages should be clear and unobstructed, with no discharge present. Observe the nasal septum. It is normally straight and un-perforated, dividing the nasal cavity into two chambers of relatively equal size and shape. The mucous membranes should be pink.
b. Examine the sinuses for tenderness. Avoiding the eyes, use the fingertips to direct manual pressure upward over the frontal sinuses. With the thumbs, direct pressure upward over the lower edge of the maxillary bones to examine the maxillary sinuses.
a. When examining the mouth and throat, begin with a general observation of the voice quality. Are raspines or hoarseness detected in the voice? Make a note of the breath odor. Observe the lips for moisture, color, and the presence of abnormalities such as masses, lesions, or discolorations.
b. Using a tongue depressor and penlight, examine the inside of the mouth.
(1) Note the number and condition of the teeth.
(2) Note the color and texture of the gums and look for the presence of swelling or discharge.
(3) Observe the pharynx, looking for masses, exudate, or inflammation.
(4) Observe the tonsils for inflammation or exudate.
(5) Observe the protruded tongue for size, color, moisture, symmetry, and the presence of any abnormal lesions.
a. The normal resting adult breathes 16-20 times per minute. Except for an occasional deeper breath (sigh), breathing is maintained at a fairly regular rate, rhythm, and depth. Any disease or injury that affects the respiratory system, the chest wall, or the oxygen carrying ability of the blood will usually affect the respiratory rate or the effort required to breathe. If breathing movements are painful, breathing may become irregular or the patient may be reluctant to take a breath of sufficient depth to aerate the lungs.
b. When observing a patient's respirations, the following should be noted.
(1) Rate. The number of breathes per minute.
(2) Rhythm. The pattern or regularity of the breathing.
(3) Depth. Shallow or deep inspiration.
a. Dyspnea. Difficult or labored breathing, normally requiring considerable exertion by the patient.
b. Apnea. Temporary cessation of breathing. A period of apnea may last for 30-60 seconds.
c. Tachypnea. Quick, shallow breathing.
d. Bradypnea. Abnormal slowness of breathing.
e. Hypoventilation. A state in which there is a reduced amount of air entering the pulmonary alveoli.
f. Hyperventilation. A state in which there is an increased amount of air entering the pulmonary alveoli.
g. Stertorous Respiration. Breathing accompanied by abnormal snoring sounds.
h. Cheyne-Stokes Respiration. An irregular rhythmic breathing pattern that begins with slow, shallow respirations that increase in rate and depth and then gradually decline again. A period of apnea lasting 10-60 seconds follows, and the pattern then repeats itself.
a. Auscultation (listening with a stethoscope) aids in assessing air flow through the lungs and determining the presence of fluid or mucus. Breath sounds vary according to the proximity of the large bronchi. Sounds are louder and courser near the large bronchi and over the anterior chest in general. Peripherally, the sounds are softer and finer.
b. To auscultate the chest, have the patient sit erect, or position the patient first on one side and then on the other if the patient is unable to sit. With a stethoscope, listen to the lungs as the patient breathes in and out with the mouth open. Follow a methodical pattern, comparing symmetrical areas on the left and right, traveling from apex to base. Listen both anteriorly and posteriorly.
c. Breath sounds, the sounds of air moving into the lungs during inspiration and out during expiration, should be clearly heard over all lung fields. Normal breath sounds are smooth and clear. Wheezing, rattling noises, or the absence of sound over a particular area is abnormal.
d. Nursing personnel should always auscultate the patient's lungs before and after percussion or coughing and deep breathing exercises. In this way, an observation regarding the effectiveness of the treatment can be made.