Respiratory Assessment.

Respiratory illnesses often require acute care admissions and are a leading cause of death globally, thus creating a financial burden for healthcare systems. Home healthcare clinicians can significantly reduce morbidity and hospital readmissions by becoming proficient at respiratory assessment. This article aims to assist homecare clinicians in performing a respiratory assessment in a logical and structured approach, including inspection, palpation, percussion, and auscultation. This article reviews the anatomy and physiology of the respiratory system and describes subjective and objective respiratory assessment. It is anticipated that becoming adept at these skills will enable home healthcare clinician to assess and identify those patients at risk for deterioration and readmission.

Respiratory assessment: undertaking a physical examination of the chest in adults.

Nurses frequently encounter patients in respiratory distress or with respiratory complications, whether from acute disease or a long-term condition. A physical examination of the chest should be conducted as part of a comprehensive respiratory assessment of the patient, and should follow a systematic approach that includes inspection, palpation, percussion and auscultation. Nurses undertaking these hands-on components of respiratory assessments need to have adequate knowledge of the procedures involved, as well as practical skills that need to be practised under supervision. This article outlines how to undertake a physical examination of the chest in adults.

Tabla: A Proof-of-Concept Auscultatory Percussion Device for Low-Cost Pneumonia Detection.

Pneumonia causes the deaths of over a million people worldwide each year, with most occurring in countries with limited access to expensive but effective diagnostic methods, e.g., chest X-rays. Physical examination, the other major established method of diagnosis, suffers from several drawbacks, most notably low accuracy and high interobserver error. We sought to address this diagnostic gap by developing a proof-of-concept non-invasive device to identify the accumulation of fluid in the lungs (consolidation) characteristic of pneumonia. This device, named Tabla after the percussive instrument of the same name, utilizes the technique of auscultatory percussion; a percussive input sound is sent through the chest and recorded with a digital stethoscope for analysis. Tabla analyzes differences in sound transmission through the chest at audible frequencies as a marker for lung consolidation. This paper presents preliminary data from five pneumonia patients and eight healthy subjects. We demonstrate 92.3% accuracy in distinguishing between healthy subjects and patients with pneumonia after data analysis with a K-nearest neighbors algorithm. This prototype device is low cost and simple to implement and may offer a rapid and inexpensive method for pneumonia diagnosis appropriate for general use and in areas with limited medical infrastructure.

The consequences of using advanced physical assessment skills in medical and surgical nursing: A hermeneutic pragmatic study.

AIMS AND OBJECTIVES: The aim of this study was to explore the consequences of the nurse's use of advanced assessment skills on medical and surgical wards. BACKGROUND: Appropriate, accurate, and timely assessment by nurses is the cornerstone of maintaining patient safety in hospitals. The inclusion of "advanced" physical assessment skills such as auscultation, palpation, and percussion is thought to better prepare nurses for complex patient presentations within a wide range of clinical situations. DESIGN: This qualitative study used a hermeneutic pragmatic approach. METHOD: Unstructured interviews were conducted with five experienced medical and surgical nurses to obtain 13 detailed narratives of assessment practice. Narratives were analyzed using Van Manen's six-step approach to identify the consequences of the nurse's use of advanced assessment skills. RESULTS: The consequences of using advanced assessment skills include looking for more, challenging interpretations, and perseverance. The use of advanced assessment skills directs what the nurse looks for, what she sees, interpretation of the findings, and her response. It is the interpretation of what is seen, heard, or felt within the full context of the patient situation, which is the advanced skill. CONCLUSION: Advanced assessment skill is the means to an accurate interpretation of the clinical situation and contributes to appropriate diagnosis and medical management in complex patient situations. RELEVANCE TO CLINICAL PRACTICE: The nurse's use of advanced assessment skills enables her to contribute to diagnostic reasoning within the acute medical and surgical setting.

Assessment of the primary stability of dental implants in artificial bone using resonance frequency and percussion analyses.

PURPOSE: There is no quantitative gold standard instrumentation to assess the quality of implant osseointegration. The purpose of this exploratory study was to evaluate the response of two devices (one based on resonance frequency analysis, the Osstell device, and another that analyzes the percussion energy response, the Periometer) to assess the primary stability of implants embedded in artificial bone models. MATERIALS AND METHODS: Standard implants were placed into polyurethane blocks of varying densities, and the two mechanical devices were challenged to test the specimen block series. Both analysis of variance and regression analysis were used to examine the output from each device over each series of specimen blocks as well as to directly compare outputs between the two devices. RESULTS: The stability of the implants increased with the foam density for solid block specimens. Linear regression analysis showed significant correlation between the two instruments for testing with monolithic blocks ( r2 = 0.984). Both devices also indicated that a hybrid block with the greatest density at the top provided the best implant stability versus a hybrid block with relatively low density at the top of the block. However, resonance frequency analysis readings seemed to be more dependent on the density of the top layer of the hybrid blocks. CONCLUSION: Osstell and Periometer readings were in good agreement for monolithic blocks, and they were reasonably consistent when blocks of hybrid density were tested.

[Periodontal tissue spectral assessment].

The periodontal condition was investigated by means of tooth natural frequency assessment. The correlation between tooth natural frequency and mobility was found out. The comparative estimation of percussion and spectral methods for natural frequency assessment revealed the percussion method to be more complicates because the initial acoustic signal is disturbed by external noises and hammer sound. The spectral method allows receiving reliable and reproducible results when using modified two-parametrical periodontometer.

Measurement of dental implant stability by resonance frequency analysis and damping capacity assessment: comparison of both techniques in a clinical trial.

PURPOSE: Two noninvasive methods to measure dental implant stability are damping capacity assessment (Periotest) and resonance frequency analysis (Osstell). The objective of the present study was to assess the correlation of these 2 techniques in clinical use. MATERIALS AND METHODS: Implant stability of 213 clinically stable loaded and unloaded 1-stage implants in 65 patients was measured in triplicate by means of resonance frequency analysis and Periotest. Descriptive statistics as well as Pearson's, Spearman's, and intraclass correlation coefficients were calculated with SPSS 11.0.2. RESULTS: The mean values were 57.66 +/- 8.19 implant stability quotient for the resonance frequency analysis and -5.08 +/- 2.02 for the Periotest. The correlation of both measuring techniques was -0.64 (Pearson) and -0.65 (Spearman). The single-measure intraclass correlation coefficients for the ISQ and Periotest values were 0.99 and 0.88, respectively (95% CI). No significant correlation of implant length with either resonance frequency analysis or Periotest could be found. However, a significant correlation of implant diameter with both techniques was found (P < .005). The correlation of both measuring systems is moderate to good. It seems that the Periotest is more susceptible to clinical measurement variables than the Osstell device. The intraclass correlation indicated lower measurement precision for the Periotest technique. Additionally, the Periotest values differed more from the normal (Gaussian) curve of distribution than the ISQs. Both measurement techniques show a significant correlation to the implant diameter. CONCLUSION: Resonance frequency analysis appeared to be the more precise technique.

The process of conducting a physical assessment: a nursing perspective.

Physical assessment is a new responsibility for many nurses in the UK who are expanding their parameters of advanced clinical practice. A physical assessment framework can be used by both community and acute care nurses as a guide to the process of conducting a physical assessment. The framework presented here consists of the following sequence of steps: identifying the purpose of the assessment; taking a health history; choosing a comprehensive or focused approach; and examining the patient using the sequence of inspection, palpation, percussion and auscultation. The next step, interpretation of the clinical findings, which results in either the recognition of abnormality or identification of a differential diagnosis, then becomes the basis for clinical decision making. This paper describes a comprehensive, head-to-toe assessment as one example of the application of this physical assessment framework in clinical practice.

Respiratory assessment.

The ability to carry out and document a full respiratory assessment is an essential skill for all nurses. The elements included are: an initial assessment, history taking, inspection, palpation, percussion, auscultation and further investigations. A prompt initial assessment allows immediate evaluation of severity of illness and appropriate treatment measures may warrant instigation at this point. Following this, a comprehensive patient history will be elicited. Clinical examination of the patient follows and involves inspection, palpation, percussion and auscultation. At this point, consideration must be given to preparation of a light, warm, quiet, private environment for examination and suitable patient positioning. Inspection is a comprehensive visual assessment, while palpation involves using touch to gather information. The next stages are percussion and auscultation. While percussion is striking the chest to determine the state of underlying tissues, auscultation entails listening to and interpreting sound transmission through the chest wall via a stethoscope. Finally, further investigations may be necessary to confirm or negate suspected diagnoses.

Resonance frequency analysis and damping capacity assessment. Part I: an in vitro study on measurement reliability and a method of comparison in the determination of primary dental implant stability.

OBJECTIVES: The aims of this in vitro study were to evaluate reliability of the Osstell and Periotest devices in the assessment of implant stability and to perform a method comparison. MATERIAL AND METHODS: Commercial dental implants were inserted into bovine rib segments of different anatomical origins and densities. Repeated measurements were performed, varying (a) the torque-in force of the devices' attachment screw (the Osstell transducer and the ball attachment, insert for the Periotest device), (b) the insertion site bone quality, and (c) the thread exposure in simulated peri-implant bone defects. RESULTS: Both methods were comparably reliable and showed a strong association to each other in the classification of implant stability. As opposed to torque-forced screw attachment, the variations in bone composition, differences in inter-implant stability of adjacent implants, and peri-implant bone reduction were statistically significant for both methods. CONCLUSIONS: Both non-invasive diagnostic devices seem to be useful in the long-term follow-up of implant integration.

Resonance frequency analysis and damping capacity assessment. Part 2: peri-implant bone loss follow-up. An in vitro study with the Periotest and Osstell instruments.

OBJECTIVE: We compared the performance of damping capacity assessment (Periotest device) to resonance frequency analysis (Osstell device) in the assessment of peri-implant bone loss in an in vitro experiment. MATERIAL AND METHODS: Screw-type oral implants were polymerized into acrylic blocks. Peri-implant bone loss was simulated by successively removing defined portions of material surrounding the implants in millimeter increments. Measurement values of both devices were compared by assessing the associated measurement errors, by calculating correlation analyses and drawing scatterplots, and by means of regression analysis referring to increasing bone loss. RESULTS: Both devices produced comparable results suggesting agreement of the measured implant stability values to the actual loss of peri-implant resin. There was a noticeable correlation of the Periotest and Osstell implant stability values. CONCLUSION: The results of this experiment suggest agreement in predicting the actual implant stability with both the instruments with the Osstell instrument being the more precise device.

Restoration of the root-filled tooth: pre-operative assessment.

This is the first in a series of four papers related to the management of root canal treated teeth. When teeth compromised by extensive restorations become non-vital, suggestions have been given as to how root canal treatment can be carried out with the greatest chance of success. Once root canal treated, either by a previous dentist or by the current dentist, a review of the assessment process that should be carried out prior to placing costly indirect definitive restorations is given. It will be clear that post-retained restorations are mainly reserved for anterior or single-rooted teeth, posterior teeth rarely requiring a post for core retention. The second paper in this series describes the basic tooth preparation that should be carried out prior to placing a post. Depending on the type of post system used, further modifications to tooth preparation may be required and the cementation techniques may also have to be modified. The third paper therefore discusses the various post types, when and how they should be used for optimum results. The final paper addresses reinforcement and restoration of compromised root canals, such as those with immature, open apices, or those that have been over-prepared for previous post-retained restorations.

Semiología y clínica propedéutica de los aneurismas de aorta torácica no complicados / Semiology and clinical propedeutics of non-complicated thoracic aorta aneurysms

El objetivo de nuestro trabajo es el de remozar la signosintomatología de los aneurismas de aorta torácica no complicados. Ya que en la crisis socioeconómica, al solicitar exámenes complementarios se debe evaluar la ecuación costo-beneficio; y en este sentido el conocimiento y la orientación clínica continúan siendo insuperables.

Assessment of osseointegration by nonlinear dynamic response.

Quantitative assessment of osseointegration remains a goal of researchers and clinicians alike. In this study, an instrument was designed for this purpose and tested in an animal model. Effective mechanical impedance, linearized for quasi-static force, was measured in 22 implants placed in the hind tibiae of 2 large hounds. The results demonstrate that in this animal long-bone model, the effective impedance of titanium root-form implants exhibits a degree of nonlinear behavior correlated with their state of osseointegration. This observation may be the basis for useful clinical instrumentation.

[The use of the Periotest method for the clinical assessment of the efficacy of dental implantation]. / Primenenie periotest-metoda dlia klinicheskoi otsenki éffektivnosti dental'noi implantatsii.

The paper describes a modern diagnostic method: Periotest for assessing the stability of intraosseous implants. The mobility of implants after remote and immediate implantation is assessed in 65 patients with dentition defects. The study yielded complete information on the status of tissue complex, detected the early signs of impaired bone integration after implantation, and helped more reliably predict the results.

Effect of combined kinetic therapy and percussion therapy on the resolution of atelectasis in critically ill patients.

BACKGROUND: Some critically ill patients have difficulty in mobilizing their respiratory secretions. These patients can develop pulmonary atelectasis that may result in hypoxemia. There are some data to show that atelectasis may be prevented by turning a patient from side to side utilizing special beds. STUDY OBJECTIVES: To determine the role of kinetic therapy (KT) combined with mechanical percussion (P) in the resolution of established atelectasis of the lungs and hypoxemia in critically ill, hospitalized patients. (KT was defined as rotation of a patient along the longitudinal axis of > or = 40 degrees to each side continuously.) DESIGN: Prospective and randomized study (2:1 test to control group). PATIENTS: Twenty-four patients with respiratory failure, either mechanically ventilated or spontaneously breathing, who demonstrated segmental, lobar, or unilateral entire lung atelectasis were studied. SETTING: Medical ICU and adult respiratory ward in a county hospital in New York. INTERVENTIONS: Seventeen patients were treated with KT combined with mechanical P using a KT system (Triadyne Kinetic Therapy System; KCI; San Antonio, TX). Seven patients received manual repositioning and manual P every 2 h. Both groups received similar conventional therapy with inhaled bronchodilators and suctioning. RESULTS: Partial or complete resolution of atelectasis was seen in 14 of 17 patients (82.3%) in the test group as compared with 1 of 7 patient (14.3%) in the control group. The median duration to resolution of atelectasis was 4 days in the test group. Bronchoscopy was performed in 3 of 7 patients in the control group, but in none of the patients in the test group. A cost of $720 was incurred per patient for utilizing the specialty beds for a mean duration of 4 days. An improvement in oxygenation index occurred in the test group (change in baseline PaO2/fraction of inspired oxygen from 207.4+/-106.7 mm Hg to 318+/-100.7 mm Hg) at the end of therapy, while the control group showed a reduction over a similar duration of time (181.3+/-96.3 mm Hg to 112+/-21.2 mm Hg). CONCLUSIONS: KT and mechanical P therapy resulted in significantly greater partial or complete resolution of atelectasis as compared with conventional therapy. There was a generalized trend toward statistical significance in the improvement of oxygenation and a reduced need for bronchoscopy in the group receiving KT and P therapy.

A new provocative test for carpal tunnel syndrome. Assessment of wrist flexion and nerve compression.

To establish the value of median nerve compression with wrist flexion as a provocative test for carpal tunnel syndrome (CTS), we performed a prospective study of 64 patients (95 hands) with CTS confirmed by electrodiagnostic studies and 50 normal subjects (96 hands). We recorded results for the common provocative tests (Tinel's percussion test, Phalen's wrist flexion test and the carpal compression test) and the new test which combines wrist flexion with median nerve compression. Using a receiver operator characteristic curve (ROC) technique, we found that the optimal cut-off time for the wrist-flexion and median-nerve compression test was 20 s, giving a sensitivity of 82% and a specificity of 99%. These results were significantly better than for Phalen's wrist flexion test (61% and 83%, respectively) and for the sensitivity of Tinel's test (74%). The positive predictive values of the wrist flexion and median-nerve compression test, which is more important clinically, were 99%, 95% and 81% at population prevalences of 50%, 20% and 5%, respectively. These were significantly better than those of the three other provocative tests at each prevalence. Electrodiagnostic studies have significant false-positive and false-negative rates in CTS, and therefore provocative tests remain important in its diagnosis. We have shown that wrist flexion combined with the median-nerve compression test at 20 s, is significantly better than the other methods, and may thus be clinically useful.