1. What cardiopulmonary physical assessment findings might be present in a patient who smokes? How would you approach this patient for history taking and assessment?

There are several physical assessment findings in patients that smoke and a through respiratory and cardiovascular physical exam should be conducted. Dyspnea, coughing with our without sputum, and wheezing may be indicative of a respiratory disease related to smoking. Also, smokers may have a barrel chest, hypoxia, and take much longer to exhale a full breath. More severe assessment findings would include accessory muscle use, pursed lip breathing, tri-poding, and nail bed cyanosis.
A complete family history, patient medical history and history of present illness should be obtained followed by a complete set of vital signs. Observe the rate, depth and rhythm of respirations. Note the shape and configuration of the chest wall. Severe thoracic deformities, such as scoliosis and kyphosis may reduce the lung volume. Observe the position your patient is in while at rest to take a breath. A relaxed position and the ability to support ones own weight with arms comfortably at the sides. Patients with respiratory diagnoses may sit in a tripod position (leaning forward with arms braced against knees, chair or bed). (Jarvis, 2012 p422.) Assess skin color; a bluish discoloration (cyanosis) can indicate hypoxia. Assess chest expansion by placing your hands on a patient’s posterolateral chest. Gently bring your thumbs to the midline and have the patient take a deep breath in and out. Simultaneously, you will watch and feel the chest expand. Place your hands on the upper chest and apex, then anterior chest and repeat the process. Percuss the anterior and posterior aspects of the chest. Listen to the presence and quality of a patient’s lung sounds with a stethoscope and identify any adventitious sounds. A hand held spirometer measures the total volume exhaled. Chronic smokers will have a lower spirometer result than a non-smoker. Finally obtaining smoking history is very important, and asking questions such as: Do you smoke? Cigaretts or Cigars? When did you start? How many packs per day do you smoke? Have you tired to quit? Most smokers know smoking is harmful to their health and should quit. Instead of repeating information they often hear, offer ways to modify their behavior, such as activities or stressors that may lead to smoking.