Respiratory Assessment

Hypoxia

Inadequate tissue oxygenation at the cellular level

Decreased Fremitus

Occurs with *obstruction* of vibrations Ex: Atelectasis, Pneumothorax

Auscultation - Anterior Chest Wall

Use diaphragm of stethoscope and listen to one full respiration in each location. Compare side to side in symmetrical locations.

Auscultation - Posterior Chest Wall

Using the same points as percussion, palpation, etc. Instruct client to sit, leaning forward slightly. Can ask patient to cross arms. Instruct client to breath more deeply than normal through the mouth. Use diaphragm of stethoscope and listen to one full respiration in each location. Compare side to side in symmetrical locations.

Pulmonary Function/Spirometry

Usually done in the pulmonologist's office Looks at every portion of respiration (multiple different readings)

Respiratory Physiology

Ventilation Perfusion Oxygen Transport Inspiration/Expiration Diffusion Carbon Dioxide Transport

Hyperventilation

Ventilation in excess of that required to eliminate carbon dioxide produced by cellular metabolism

Environment - Developmental Influences

air quality stress (suppresses immune system and increases risk of infection) Altitude (higher altitude = lower oxygen levels)

The term "Kussmaul" refers to a high-pitched, harsh, crowing inspiratory sound that occurs due to partial obstruction of the larynx. a) True b) False

b) False -Stridor is the correct answer

Which diagnostic test/exam would best measure a client's level of hypoxemia? a) Chest x-ray b) Pulse oximeter reading c) ABG d) Peak expiratory flow rate

c) ABG (arterial blood gas) hypoxemia is low arterial blood oxygen levels

Bronchovesicular

heard over major bronchi between scapulae and upper sternum 1st and second ICS (inspiration = expiration)

Vesicular

heard over periphery of lung (longer inspiration/short expiration)

Bronchial

heard over trachea & larynx (short inspiration/ longer expiration) (shouldn't hear over lower part of the lung = might mean fluid which transmits sound differently)

Cheyne-Stokes

increasing irregular pattern and then decreasing and periods of apnea

Biot

irregular pattern with apnea

Increased Fremitus

Occurs with *consolidation* of the lung tissue

An elderly patient with pneumonia may appear with which symptoms first? 1) Altered mental status and dehydration 2) Fever and chills 3) Hemoptysis and dyspnea 4) Pleuritic chest pain and cough

1) Altered mental status and dehydration -older adults are atypical and don't have the same response as others -this is a normal response for older adults with illnesses

Which respiratory disorder is most common in the first 24-48 hours after surgery? 1) Atelectasis 2) Bronchitis 3) Pneumonia 4) Pneumothorax

1) Atelectasis don't take deep breaths which causes mucus buildup and blocked airways --> leads to alveolar collapse common post-op complication

A-P Diameter Normal

1:2 A-P Diameter No Transverse Diameter

Which additional assessment data should immediately be gathered to determine the status of a patient with a respiratory rate of 4 bpm? 1) Arterial blood gas and breath sounds 2) Level of consciousness and pulse oximetry value 3) Breath sounds and pulses 4) Pulse oximetry and heart sounds

2) level of consciousness and pulse oximetry value - patients can control their respiratory rate, more awake may increase rate

A pulse oximeter gives what type of information about a patient? 1) Amount of carbon dioxide in the blood 2) The respiratory rate 3) The amount of oxygen in the blood 4) The percentage of hemoglobin carrying oxygen

4) The percentage of hemoglobin carrying oxygen

Pulmonary System

Airways and lungs Ventilation Movement of air into/out of the lungs Respiration Exchange of oxygen/carbon dioxide Alveolar capillary/capillary cell membrane

Hypoventilation

Alveolar ventilation inadequate to meet the body's oxygen demand or to eliminate sufficient carbon dioxide

Inspiration/Expiration

An active process stimulated by chemical receptors in the aorta and a passive process for expiration

Physical Examination - Palpation

Anterior Posterior Palpate for pain/discomfort

Atelectasis Definition

Anything that reduces ventilation or causes the alveoli to collapse (secretions, foreign body, tumor)

Assessment Steps

Assessing for Risk factors - demographics - age - gender - cardiovascular/pulmonary issues - environment - lifestyle Physical Exam Assess Breathing Patterns: (*Shallow or deep) Eupnea: NI; 12-20 bpm Tachypnea > 24 Bradypnea < 10 Kussmaul Biot's Cheyne-Stokes Apnea *Risk for atelectasis* - surgery - any blockage of airway

Chest Expansion

Asymmetry with an airway obstruction, pleural effusion, or pneumothorax Normal = symmetry As they take a deep breath your thumb and fingers should move apart

A-P Diameter Abnormal

Barrel Chest = 1:1 A-P Diameter

Cyanosis

Blue discoloration of the skin and mucous membranes Desaturation of hemoglobin Late stage hypoxia

Auscultate Normal Breath Sounds

Bronchial Bronchovesicular Vesicular

Voice Sounds

Bronchophony Egophony Whispered Pectoriloquy

Apnea

Cessation of breathing

History

Cough (yes - then PQRSTU) Shortness of Breath (yes - then PQRSTU) Chest Pain with Breathing Past History of Respiratory Infections Past History of Respiratory Diseases Past History of Allergies Cigarette Smoking Environmental Exposure

Assessment of Cough and Sputum

Cough - Recurring or productive or chronic - Type - Other SX - normal protection mechanism for the body - coughs become persistent, recurring, or very productive, last longer then 3 weeks - can be dry, hacking, productive (bringing up mucus) - ask about other symptoms (fever, chest congestion, sneezing, sore throat, etc.) (can lead you to various disease possibilities) Sputum Appearance - COLOR - clear/white = allergies green/yellow = allergies or infection black = soot or smoke inhalation rust = pneumonia or TB = presence of blood pink and frothy = pulmonary edema Odor = Infection Amount Timing

Changes in the Older Adult

Decline in respiratory muscle strength results in decreased ability to cough Loss of elasticity causes more rigid lung Decreased alveoli causes less gas exchange Decreased ventilation causes dyspnea with exertion Increased respiratory rate, more shallow Greater risk for developing kyphosis Greater risk for falls and rib fractures

Physiological Factors

Decreased oxygen-carrying capacity (ex: anemia) Decreased inspired oxygen (ex: asthma, high altitude, obstruction) Hypovolemia (not enough fluid/plasma in blood) (ex: dehydration, shock) (not enough volume = decreased perfusion to tissues) Increased metabolic rate (pregnancy, hyperthyroidism, etc.)

Kussmaul

Deep, labored breathing

Inspiration

Diaphragm and intercostals contract Thoracic cavity size increases Lung volume increases Intrapulmonary pressure decreases Air rushes into lungs to equalize pressure *Surfactant*

Expiration

Diaphragm and intercostals relax Intrapulmonary pressure rises Air is expelled

Carbon Dioxide Transport

Diffuses into red blood cells and is hydrated into carbonic acid

Pulse Oximetry

Estimates arterial blood oxygen saturation (Sao2) Sao2: reflects % of Hgb molecules carrying oxygen Healthy Patients: 95-100% Interferes: Movement. Nail polish/nails, Cold environment

Anterior Palpation

Evaluate *symmetric chest expansion* by placing hands on anterolateral chest wall along the costal margins. Evaluate symmetric chest expansion by placing hands on posterolateral chest wall with thumbs at T8 to T10.

Posterior Palpation

Evaluate *symmetric chest expansion* by placing hands on posterolateral chest wall with thumbs at T8 to T10. Evaluate symmetric chest expansion by placing hands on posterolateral chest wall with thumbs at T8 to T10.

Diffusion

Exchange of respiratory gases in the alveoli and capillaries

Tachypnea

Fast breathing > 24 bpm

Precuts Excavatum

Funnel Chest

Physical Examination - Inspection

General Inspection Anterior Inspection Posterior Inspection

Nursing Role

History Assessment Diagnostic Tests: CBC (red blood cells, anemic or not) ABG (carbon dioxide in blood) TB skin test (TB exposure) Pulmonary Function/Spirometry (information of ventilation and respiration) Bronchoscopy (able to look and/or take specimens at bronchial tree) Lung Scan (look at lungs for blood clots, pulmonary emboli, etc.) Pulse Oximetry Thoracentesis (removes fluid from pleural space) Chest X-ray (show density of the lung) Sputum cultures - (see what is growing) For C&S For AFB For Cytology

Alterations in Respiratory Functioning

Hyperventilation Hypoventilation Hypoxia Cyanosis

Lifespan - Development Influences

Infants/premature babies Earlier then 34 weeks don't have surfactant = alveoli can collapse and they can go into respiratory distress Immature Immune system and brain also - controls breathing - infants and premature babies can have irregular breathing - higher risk of infection Much more narrow airways (easier for airway collapse) Children and Toddlers are at high risk for upper respiratory infections

What Happens When We Breathe?

Inspiration Expiration

Anterior View - Lobes of the Lungs

Left Side has 2 lobes Right Side has 3 lobes

General Inspection

Level of consciousness Position assumed by patient to breathe Effort, quality, rate, rhythm Skin color and condition (cyanosis, pallor) Anteroposterior diameter/ Transverse diameter (barrel chested?)

Factors That Influence Pulmonary Function

Life span and development (e.g., respiratory distress syndrome, upper respiratory infections [URIs], adolescent smoking, cardiac insufficiency) Environment (e.g., stress, allergies) Lifestyle (e.g., nutrition, exercise, substance abuse) Medications Smoking Pathophysiological Conditions

Oxygen Transport

Lungs and cardiovascular system

Assessment of Respiratory Effort

Nasal Flaring: Helps reduce resistance to airflow in nose (done when a person has difficulty breathing) (How hard is the person working to breath?) Retractions: - Use of Accessory Muscles (movement of subclavian muscles) (retraction of ribs when breathing - Grunting (noises difficult breathing, forcing air out on a closed epiglottis) - Body position (many people who are in respiratory distress use tripod position, sitting up with hands braced in front of them) - Paroxysmal nocturnal (patient wakes up suddenly in the middle of the night and can't breath) (Ask how many pillows a person sleeps with) - Dyspnea (PND) - Stridor (high pitched crowing sound on inspiration due to a partially obstructed airway) (croup, foreign body) - Wheeze (musical sounds, partially obstructed small airways, usually obstructed by mucus)

Eupnea

Normal Breathing 10 - 20 bpm

Lifestyle - Developmental Influences

Obesity will restrict ventilation - more likely to get an infection - higher risk for sleep apnea Exercise - respiratory rate increased while exercising Smoking - causes cancer - causes chronic inflammation - increases secretions Pregnancy - increases the oxygen demand - breath faster in late term pregnancy Work Environments - coal mine - construction (dust) - casino/bar (second hand smoke) - firefighter - nail salon - kitchen workers (grease, smoke, steam)

Physical Examination

Palpation using **Tactile Fremitus**: Fremitus - palpable vibrations transmitted through the bronchopulmonary tree to the chest wall when the patient speaks Palpate anterior and posterior Use palmar base or ulnar edge of hand. Compare symmetrical areas for tactile fremitus as patient says "99". Normal - most prominent over major bronchi, decreases as you progress downward

Peak Flow Monitoring

Peak expiratory flow rate (PEFR): Measures air exhaled with forcible effort Monitors, NOT diagnosis of asthma Small hand-held apparatus - person should stand and take a deep breath - then exhale forcefully into machine (for as hard and long as possible) - will pick up subtle changes in air flow - measured in meters per minute - should take 3 readings and then take the highest of the three readings - can determine person's personal best over time

Percussion (1)

Percuss in between the rib space Both sides (back and forth Start right above the shoulder Want to hear resonance Hyper-resonance is lower-pitched booming sound (excess air in the lung = pneumothorax, emphysema, overinflation) Dull sound if there is fluid over the space (pneumonia, effusion (fluid in lining), or tumor) May be dullness as you move further down due to organs (liver and kidney) Must be skin on skin

Assessing Oxygenation Status

Physical examination: Using *inspection, palpation, percussion, and auscultation* Breathing pattern: - Eupnea, bradypnea, tachypnea - Apnea, Kussmaul, Biot, Cheyne-Stokes Respiratory effort (the amount of work it takes a person to breath) Pulse oximetry

Factors Affecting Oxygenation

Physiological Factors Conditions Affecting Chest Wall Movement

Precuts Carinatum

Pigeon Breast

Conditions Affecting Chest Wall Movement

Pregnancy (infant pushes up and lungs can't expand) Obesity (much more difficult, abdominal organs pushing up on lungs) Musculoskeletal Abnormalities (Kyphosis, Scoliosis) Trauma Neuromuscular disease CNS alterations

Pathophysiological Conditions

Pulmonary System Abnormalities: - structural Abnormalities - airway Inflammation (allergies or asthma) - obstruction (foreign body - children/infants/older adults) - atelectasis - CNS Abnormalities (head injury, stroke, etc.) - neuromuscular - abnormalities Respiratory Infections: URI: Influenza (very young and very old) LRI: Pneumonia

Assessment

Pulse Oximetry Peak Flow Monitoring

Bronchophony

Repeat 99 Normal = muffled Abnormal (ex: fluid in lungs) = Hear 99

Anterior Inspection

Shape and configuration of the chest wall Costal angle (angle between the ribs) Symmetry of the thoracic cage Retraction or bulging of interspaces Use of abdominal muscles

Posterior Inspection

Shape and configuration of the chest wall Kyphosis/Scoliosis Symmetry of the thoracic cage Position of the spinous processes

Bradypnea

Slow breathing < 10 bpm

Percussion

Start at apices and work down, going side to side Resonance: low-pitched, clear, hollow sound that predominates healthy lung tissue in the adult Hyperresonance: lower-pitch, booming (emphysema or pneumothorax) Dull" soft, muffled thud (abnormal density like in pneumonia, pleural effusion, atelectasis, or tumor)

Perfusion

The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs

Ventilation

The process of moving gases into and out of the lungs

Normal Breath Sounds - Posterior Chest

Three T

Percussion (2)

Typically percuss more on the back Go around and down Flatness over scapula Resonance over ribs Lower into bases you may have more dullness due to organs (liver, pancreas, and kidneys)

The Airway

Upper: Above larynx Nasal passages, mouth, and pharynx Lower: Below Larynx Trachea, bronchi, bronchioles Considered sterile